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    • Abstract: 250 EAST PARK AVE LAKE WALES, FL 33853 (PH) 800-394-2767 EXT. ... Ramsgate Legal Dept. 250 East Park Avenue. Lake Wales, FL 33853. If you have any questions, ...

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Welcome To Ramsgate Insurance, Inc.
To get appointed with Ramsgate, simply complete the two
attached pages and mail them along with proof of your Error
& Omissions policy and producer licenses (Agent P&C) to:
Ramsgate Legal Dept.
250 East Park Avenue
Lake Wales, FL 33853
If you have any questions, please call our legal
800-394-2767 Ext.1175
Or email to: [email protected]
250 EAST PARK AVE LAKE WALES, FL 33853 (PH) 800-394-2767 EXT. 1100 (FX) 800-837-9376 www.RamsgateInsurance.com
THIS AGREEMENT is made between
address hereinafter
referred to as AGENT and RAMSGATE INSURANCE, INC., hereinafter referred to as RAMSGATE.
The Agent agrees he is the Representative of the Insured, his customer, and is not the representative of Ramsgate.
The Agent has no authority to bind coverages with, for, or on behalf of Ramsgate, including changes on existing policies. The Agent will
indemnify and hold Ramsgate harmless for any violation of this provision. In the event that Ramsgate has delegated binding authority for
any products offered, we reserve the right to cancel that authority at any time we believe the Agency is operating outside the guidelines of
the system or if any other information comes to light to give us reason to believe that Agent may not be acting in the best interests of
Ramsgate or the carriers that we represent.
The Agent is responsible to Ramsgate for all premiums, fees, and taxes bound with Ramsgate and will pay same to Ramsgate on the date
due whether or not the Agent collects from the insured (does not apply to direct-bill policies). The Agent agrees to pay Ramsgate on the
date due whether or not the policy has been received by the Agent.
In the event of cancellation or reduction in premium the Agent agrees to return all unearned commissions to Ramsgate immediately upon
Flat cancellation is not allowed. Cancellation cannot be effected until Ramsgate has received the original policy or a lost policy release.
Ramsgate will furnish the agent an invoice on each separate transaction and will render to the Agent a month end statement that recaps all
transactions for that month. The Agent is responsible to Ramsgate for payment of all monies shown thereon and will pay Ramsgate on
the date due whether or not the Agent has collected from his insured(s).
Full payment prior to binding or 25% down with the balance of the account being premium financed is required. For qualifying
agencies, payment terms allowed by Ramsgate are: (1) Full payment prior to binding/25% down with the balance of the account being
premium financed, (2) payment of each invoice immediately upon receipt and, (3) pay by monthly statement by the date stamped thereon.
Omission of an item from an invoice or monthly statement shall not affect the responsibility of either party to account for and pay the
other the same as if the item has been included on the invoice or monthly statement.
The Agent agrees that Ramsgate may from time to time send informational faxes and/or emails on any additional product offerings,
changes in coverages, announcements of any promotions that are pending and/or ongoing, newsletters, and any other item that Ramsgate
feels the Agency would potentially benefit from.
The Agent shall have undisputed ownership of all policies written with Ramsgate so long as the Agent is in compliance with the payment
terms of this agreement. The Agent shall remain liable to Ramsgate for the full indebtedness thereof.
The Agent will provide Ramsgate a properly completed application for each risk written and will promptly report all pertinent information
to Ramsgate and will cooperate with Ramsgate in securing all information needed by Ramsgate. The Agent will indemnify and hold
Ramsgate harmless for any violation of this provision.
The Agent will maintain Insurance Agents Errors and Omissions Professional Liability coverage throughout the term of this Brokerage
Agreement and will provide evidence of same to Ramsgate upon request and notification upon renewal.
THIS AGREEMENT supersedes all previous agreements and does constitute the entire agreement between the Agent and Ramsgate.
TITLE: TITLE: Corporate Officer
(Rev. October 2007)
W-9 Request for Taxpayer Give form to the
requester. Do not
Department of the Treasury
Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.
Business name, if different from above
Print or type
Check appropriate box: Individual/Sole proprietor Corporation Partnership
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) payee
Other (see instructions)
Address (number, street, and apt. or suite no.) Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instructions on page 4.
Sign Signature of
Here U.S. person Date
General Instructions Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. ● An individual who is a U.S. citizen or U.S. resident alien,
● A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number (TIN) ● An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate ● A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt, or
Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA.
trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners’ share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
2. Certify that you are not subject to backup withholding, or provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding
foreign partners’ share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester’s form if it is following cases:
substantially similar to this Form W-9.
● The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 10-2007)

Use: 0.1019