Bloss & Dillard, Inc. and American Modern Insurance Group
Subproducer Profile Order Form
 
Step into American Modern's e-fficient™ world of Web-based services, modernLINK. Using modernLINK, you can:
  • View billing and payment data
  • View coverage limits and other policy data
  • View claim status and payments
    		•  
  • View and print policy forms and endorsements
  • View and print applications, rates and more
  • Quote and issue policies online (for selected products)

    • It's easy to sign up for modernLINK services. Simply complete the order form below and click Submit. We will process your request and contact you with your modernLINK user ID and password.

    Important Information: To establish a profile you must have an IBM compatible PC connected to the Internet through an Internet Service Provider (ISP) and use one of the following browsers: AOL, Internet Explorer 4.0 or higher, or Netscape 4.0 or higher. Non-IBM compatible PC's and/or browsers other than those mentioned above, are not supported at this time. To ensure prompt completion of your profile please complete all items on this form.
    Fields marked with a * are required for submission.
     
    Is this order a NEW request or a CHANGE to an existing profile?      New Profile Order   Change to Existing Profile
     
    Agency Data
    Your Agency Name:  *
    Your 6-Character Subproducer Number(s) 
    with Bloss & Dillard, Inc.: 
      *
    DBA (if applicable): 
    Street Address:  *
    City:  *
    State:  * Zip:  *
     
    Subproducer Profile Administrator Information
    In the following section, please provide information on the individual who will serve as the Profile Administrator for your agency. This individual will be granted modernLINK Security Administration access which will enable him/her to add/modify/delete other users within your agency.
     
    Last Name:  *
    First:  *
    E-mail:  *
    Telephone:  ( ) *
    Fax:  ( ) *
    Profile Requested By:  *
    Telephone:  ( )
    Comments: 


         

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    Last Updated on April 6, 2005