Agent Information Applicant Information Attestation Information

Agent Information

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Agent Information Applicant Information Attestation Information

Client Information

Agent Information Applicant Information Attestation Information

Agent Attestation

  1. Submission of this referral form does not waive or amend the terms of my existing producer agreement with Crump, including but not limited to, any licensing and contracting requirements.
  2. I acknowledge that Crump may accept or reject the submitted referral in its sole and absolute discretion. Crump shall timely communicate its acceptance or rejection of the referral with me.
  3. I acknowledge that if my referral results in a placed and effective insurance policy through Crump, then I will receive total compensation in the amount of fifty percent (50%) of the placed case commissions, payable in accordance with my existing compensation level reflected in Crump’s systems on a single-case basis when I am licensed in the state of sale.
  4. In consideration of the payable compensation described above, I waive and relinquish any ownership rights concerning the referral, any policy resulting from the referral and/or entitlement to any other compensation concerning the referral to Crump.

Successful Submission

Thank you for using Sales Assist – we will take it from here. Next we will:
Your Sales Assist team will keep you informed with periodic status updates. Once the policy is placed inforce, you will receive fifty percent (50%) of the placed case commissions, payable in accordance with your existing compensation level reflected in Crump’s systems on a single-case basis when you are licensed in the state of sale.
Call your Sales Assist team at 866.417.8376 with any questions.
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