CA FAIR Plan Distribution Management

Inc., LLC, and Partnerships

"*" indicates required fields

Please complete the below with the principal/owner's information. Questions may be directed to cfpbrokers@cfpnet.com.

This Form is for all Corporations/Incorporated (Inc.), Limited Liability Companies (LLC), and Partnerships.

W9 Legal Business Name:*

California Department of Insurance Agency License #:*

Principal's Name:*

First Last

Principal's Office Phone #:*

Principal's Cell Phone #:*

Principal's Email:*

Please ensure this is the primary email address for the Principal and not a distribution list.

Please fill in your complete business address below:

Street Address 1:*

Street Address 2 (for suite, apartment, or unit numbers):

City:*

State:*

ZIP Code:*

Please checkmark the listed information applicable:*

Owner 100%

Other Owner Percentage (please check this box and fill in the "Other" response below with percentage)

Principal 100%

Other Principal Percentage (please check this box and fill in the "Other" response below with percentage)

Corporation (Inc.)

Incorporated (Inc.)

Limited Liability (LLC)

Other:

Please confirm the below:*

I have reviewed the above information to ensure it is accurate.

Phone

This field is for validation purposes and should be left unchanged.