Filling out this form assumes you are already registered as a Referring Agent with Berlin & Denys Insurance.
Please fill out all required fields. A copy will be sent to your referring agent, the agency administrator and the referring agency.
If further instructions are needed please leave them in the special
The information you provide populates our commission system. Please use only legal names and correct phone and email addresses. This will help us pay you promptly. You must use this form to be paid.
You must use this form only for referrals, we will not pay for referrals given directly to an agent and then entered on this form more than 3 days later.
801 Magnolia Street
New Smyrna Beach, FL 32168
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