ACT APPOINTMENT DATA SHEET INSTRUCTIONS
Please print clearly when completing the ACT Appointment Data Sheet. Your information will be kept strictly confidential and not be shared with anyone other than our carriers.
Fill in all applicable General Information, Contact Numbers, License Information, and Banking Information.
All Personal History questions must be answered and details must be provided for all “Yes” answers.
Sign and date the Certification at the bottom.
Read the “Authorization To Execute Contract Documents On My Behalf”. Check the box indicating you have read and understand the Authorization. Date and sign the authorization including Corporate Entity name, if applicable.
Return the ACT Appointment Date Sheet (2 pages) and the Authorization To Execute Contract Documents On My Behalf and the Efficient Forms signature page to an ACA Representative for Processing.