Agency Member Verification Form

Helps each affiliated agency confirm its contact details and staff information. It records the primary contact plus every agent's licenses, roles and directory preferences.

Use this template

In the Claude connectors directory

Page 1

Instructions

Agency name

This office is a

Main office Branch office Satellite office

Agency address

Street Address

City

State / Province

ZIP / Postal Code

Agency phone

Primary agency contact

First Name

Last Name

Section

Agent 1: name and email

First Name

Last Name

Birth month (for continuing education)

Section

Agent 2: name and email

First Name

Last Name

Birth month (for continuing education)

Section

Agent 3: name and email

First Name

Last Name

Birth month (for continuing education)

Additional agents

Section

Agent name and email

First Name

Last Name

Birth month (for continuing education)

Which license?

Property and casualty Life and health Personal lines Surplus lines

Agency role

Principal or owner Producer Customer service representative Office manager

Include in directory?

Yes No

Interested in the young agents program?

Yes No

Section

Agent name and email

First Name

Last Name

Birth month (for continuing education)

Which license?

Property and casualty Life and health Personal lines Surplus lines

Agency role

Principal or owner Producer Customer service representative Office manager

Include in directory?

Yes No

Interested in the young agents program?

Yes No

Section

Agent name and email

First Name

Last Name

Birth month (for continuing education)

Which license?

Property and casualty Life and health Personal lines Surplus lines

Agency role

Principal or owner Producer Customer service representative Office manager

Include in directory?

Yes No

Interested in the young agents program?

Yes No

Section

Agent name and email

First Name

Last Name

Birth month (for continuing education)

Which license?

Property and casualty Life and health Personal lines Surplus lines

Agency role

Principal or owner Producer Customer service representative Office manager

Include in directory?

Yes No

Interested in the young agents program?

Yes No

Section

Agent name and email

First Name

Last Name

Birth month (for continuing education)

Which license?

Property and casualty Life and health Personal lines Surplus lines

Agency role

Principal or owner Producer Customer service representative Office manager

Include in directory?

Yes No

Interested in the young agents program?

Yes No

Page 2

Closing notes

Comments

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