Use this form to designate an agency manager for your Superior Direct Connect broker portal account.
Once you have submitted the form, you may visit Superior Direct Connect
to register for an agency manager account.

BROKER PORTAL AGENCY MANAGER FORM

Agency Name:

*

Tax ID:

*

Address:

Street Address:	*
City:	*
State / Zip	* / *

Agency Manager Name:

*

Title:

*

Email Address:

*

Phone Number:

*

By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.

Name of Authorized Person:

*

Title:

*

Email Address:

*

Phone Number:

*

Initials:

*