Partner Agreement Form

Partner Agreement Form

To become an Allianz Global Assistance partner, simply fill out the form below and hit submit. You will also need to print out a copy of the W-9, complete it and mail or fax it in. Both steps need to be completed in order for your application to be processed.

AGENCY INFORMATION
All information is required. Incomplete applications cannot be processed.

Agency Name (d/b/a):  
Phone:  
Fax:  
Agency Address
Street:  
(PO Box not acceptable)
  City:  
  State:  
  Zip Code:  
Contact:  
E-mail Address:
E-mail Address for Service Fee Report:
Website Address:  
Primary Business: If other, please specify  
Is the business Incorporated?
Federal Tax ID Number:  
  Number:
CRS System: If other, please specify  
Pseudo City Code:  
Are you a member of a travel agency Co-Op, consortium or franchise?  
  If yes, which one:
  Cost Center (if applicable):
  This information is for:
 
 
PRODUCT SELECTION:
Method of Sale:
Do you currently sell Travel Protection?
  If yes, who:
Do you currently share commission with agents?

Do you require commission protection coverage for your agency?
 

 
 
What are your average sales per year?
What % of your sales are:
  Cruise %  
  Air %  
  Tour %  
 
CURRENT LICENSE DATA (Necessary for Enrollment in the Service Fee Program Only)
A license is not required in AL, DC, IA or WI.
Is there currently an individual at your agency who is licensed to sell travel insurance in your state?
If yes, please indicate and send a copy of this license to:
Address: Allianz Global Assistance
P.O. Box 72045
Richmond, VA 23236

Or fax to: (800) 762-8120
Licensee 1:
  Last Name:
  First Name:  
  Full Middle Name:
  License Number(s):  
  Expiration Date(s):
Licensee 2:
  Last Name:
  First Name:
  Full Middle Name:
  License Number(s):
  Expiration Date(s):
If no, please designate individual to be licensed:
  Last Name:
  First Name:
  Full Middle Name:

AGREEMENT
Part One
  1. The above named travel agency or travel agents (hereinafter Agency) acknowledges that it is a participant in the AGA Service Company Trust, entered into in the state of Rhode Island by and between Citizen's Trust company and World Access on May 13, 1985. The Trust is the policyholder of certain insurance policies issued by BCS Insurance Company. The Agency agrees to be bound by the terms of the Trust as long as it remains a Participant.
  2. The Agency must abide by the policies of AGA Service Company (hereinafter AGA Service Company) at all times. The Agency cannot use the logos of AGA Service Company or use the name World Access without the express written consent of AGA Service Company.
  3. The Agency must maintain a valid license to sell insurance. Service Fees will be paid only to travel agents licensed by their state department of insurance. Service Fees may be varied upon thirty days written notice to the Agency.
    1. AGA Service Company agrees to provide Agency with monthly service fee report.
    2. Agency agrees to review monthly service fee report for accuracy.
  4. Either Party may terminate this Agreement at any time upon written notice to the other.
  5. Both the Agency and AGA Service Company agree that they are independent contractors. The Agency is not acting as an employee or an agent of AGA Service Company when selling the coverage.
  6. The Agency cannot, for any reason, change or amend the insurance coverage. The Agency may not interpret or determine whether or not a claim should or would be paid. Any false or misleading statements made by the Agency about the coverage provided by AGA Service Company is the sole responsibility of the Agency.
Part Two
  1. AGA Service Company agrees to:
    1. Provide Commission Protection (if agency selected) by directly paying the agent the amount equal to 10% of the cruise, tour, or airline ticket cost on bookings for which the agent's customer has purchased the World Access-Serviced Product, cancels after the final payment has been received by the supplier, and files a payable World Access claim.
  2. The Agency agrees to:
    1. Not to impose on the client any cancellation penalty in addition to that of the supplier;
    2. Refund to the client:
      1. all monies returned by the supplier; and
      2. his/her commission amount
    3. Submit documentation required to adjudicate the claim.
 
This area serves as an electronic signature
  BY:  
  TITLE:  
  DATE:  
 
If you have any questions about completing this form call (800) 284-8300, 8am-6pm, EST.