Nation Safe Drivers
Oregon
Cover Sheet
AmTrust GAP Licensing/Appointment Procedure
All business entities and individuals writing Oregon Gap with Nation Safe Drivers must hold a
Property & Casualty (P&C) License in the state of Oregon and be appointed with AmTrust
Underwriters, Inc. Individual producers must also be affiliated with the Business Entity.
Requirements for Oregon Gap appointment with AmTrust:
1. Completed “
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5. Each business location must have a business and an individual appointment
Requirements for non-licensed producers:
If the business entity and individual representative do not possess their Property & Casualty license,
they can be obtained by applying online at www.nipr.com or www.sircon.com. Be advised that an
examination is required for this type of license, as is affiliation with the business entity. For further
information on the licensing process, please contact the Oregon Insurance Department, Producer
Licensing, at [email protected] or by telephone at (503) 947-7981
There are no fees for the Allstate Gap appointment
Mail all completed forms to:
Nation Safe Drivers
Licensing & Compliance Department
800 Yamato Road, Suite 100
Boca Raton, Florida 33431
Revised 6/1/10
AMTRUST UNDERWRITERS, INC.
AGENCY AUTHORIZATION
FOR BACKGROUND INFORMATION
To:
General Information Services, Inc. (GIS) and
AmTrust Underwriters, Inc. (AmTrust)
By affixing their signature in the space provided below, the undersigned hereby authorizes all
corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies,
former employers, the Military Service or any other private or public institution to whom inquiry is made
by GIS concerning the undersigned, to provide any information that such person or entity may have about
the undersigned to GIS and its officers and employees who are engaged in said investigation, including
without limitation, any information concerning the financial condition, past activities, credit standing,
professionalism, character, general reputation, and personal characteristics of the undersigned. The
undersigned hereby releases and holds harmless GIS, any person or entity to whom inquiry has been made
or from whom references have been sought, and AmTrust Underwriters, Inc. (AmTrust) and its affiliates
(and its and their officers and employees), from any liability arising out of or in connection with such
investigation and/or the production of said information.
The undersigned acknowledge that a consumer report or investigative consumer report (“Consumer
Report”) may be prepared summarizing this information. The undersigned acknowledges that he/she may
(1) request a copy of such Consumer Report, (2) may also request the nature and substance of all
information contained about the undersigned in the files of GIS, AmTrust or its designee, and (3) may
upon reasonable notice and during regular business hours shall have the right to inspect such files and be
accompanied by one other person. GIS, AmTrust or its designee, as applicable, are required to provide
someone to explain the content of such files. The undersigned must present proper identification and
should direct any such request to:
AmTrust Underwriters, Inc., 55 Capital Boulevard, Rocky Hill CT, 06067
– Attention, Regulatory Manager.
By:
_____________________________________
(please sign here)
________________________________________
Date
_____________________________________
(print name of agency)
________________________________________
License # of Agency
_____________________________________
Address
________________________________________
City, State, Zip
_____________________________________
FEIN
AMTRUST AFBCP
Edition 11/09
AMTRUST UNDERWRITERS, INC.
INDIVIDUAL AUTHORIZATION
FOR BACKGROUND INFORMATION
To:
General Information Services, Inc. (GIS) and
AmTrust Underwriters, Inc. (AmTrust)
By affixing their signature in the space provided below, the undersigned hereby authorizes all
corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies,
former employers, the Military Service or any other private or public institution to whom inquiry is made
by GIS concerning the undersigned, to provide any information that such person or entity may have about
the undersigned to GIS and its officers and employees who are engaged in said investigation, including
without limitation, any information concerning the financial condition, past activities, credit standing,
professionalism, character, general reputation, and personal characteristics of the undersigned. The
undersigned hereby releases and holds harmless GIS, any person or entity to whom inquiry has been made
or from whom references have been sought, and AmTrust Underwriters, Inc. (AmTrust) and its affiliates
(and its and their officers and employees), from any liability arising out of or in connection with such
investigation and/or the production of said information.
The undersigned acknowledge that a consumer report or investigative consumer report (“Consumer
Report”) may be prepared summarizing this information. The undersigned acknowledges that he/she may
(1) request a copy of such Consumer Report, (2) may also request the nature and substance of all
information contained about the undersigned in the files of GIS, AmTrust or its designee, and (3) may
upon reasonable notice and during regular business hours shall have the right to inspect such files and be
accompanied by one other person. GIS, AmTrust or its designee, as applicable, are required to provide
someone to explain the content of such files. The undersigned must present proper identification and
should direct any such request to:
AmTrust Underwriters, Inc., 55 Capital Boulevard, Rocky Hill CT, 06067
– Attention, Regulatory Manager.
By:
_____________________________________
(please sign here)
________________________________________
Date
_____________________________________
(print name of individual)
________________________________________
License # of Agent
_____________________________________
Resident Address
________________________________________
City, State, Zip
_____________________________________
Social Security Number
________________________________________
Date of Birth
AMTRUST AFBCI
Edition 11/09