Agency Interface Request

AGENCY INTERFACE REQUEST/CHANGE REQUEST

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Agency Name: /

Agency Code:

Agency Contact: Email Address: / Phone:

Request IDs How Many?(Ids should not be shared) (Please complete page 2)

Secondary/Owned Agency Codes These IDs Should Be Permitted To Access:
(For Access To More Than 9 Secondary Agency Codes, Please Send E-mail to ).
IDs Will Be Sent To Agency Contact (above)

PLEASE BE AWARE THAT POP-UP BLOCKER SOFTWARE MAY PREVENT ACCESS TO OUR ONLINE SYSTEMS

AGENT PORTAL
Add Change Delete (Effective Date: ) All System Access Will Be Deleted
Personal Lines: Entry Inquiry (only) Replacement Cost Calculator
Commercial Lines: Entry Inquiry (only)

LIFE ONLY AGENT

Add Change Delete (Effective Date: )

Explanation For Change or Delete:
DOWNLOAD
Add Change Delete (Effective Date: )
Explanation for Change or Delete:
Agency Management System:Please SelectAgency SolutionsAMS 360AMS AfWAMS PrimeAMS SagittaAppliedDORISEbix ASPEbix CD OneEbix Elite (Redshaw)Ebix InfinityEclipse (NASA)InStarMI AssistantNexsureSEMCI PartnerSpecial Agent / Version:
IVANS “Y” Account:
Batch UserID: / Personal Lines: Initial Daily
Commercial Lines: Initial Daily
Secondary/Owned Agency Codes To Be Downloaded To This Location (Separate By Comma):

ProfitCenter Approval

This area for Branch Office Use Only

When Approved (Below), Please Forward Completed Form To:

Approved By: Date:

Field Office/Profit Center: Phone:

Comments:

Questions?

Call 888.547.8547

C-3697 (Ed. 04/07)

INFORMATION NEEDED TO PROCESS YOUR REQUEST

AGENCY NAME(required): AGENCY CODE(required):

AGENCY MGMT SYSTEM: AGENCY FAX:

User’s Full Name / Does User Currently Access Harleysville Online? / Individual Licensed for Life? / Preferred Password 6-8 positions / Position/Title / User’s Email / Admin
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No

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Questions?

Call 888.547.8547

C-3697 (Ed. 04/07)