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Tranzpay Application - Business Info
1
Contact Info
2
Business Info
3
Company Info
4
Processing Volume
Product Choice
Authorized Company Contact
I am....
*
an Officer/Owner
solely a Authorized Contact, no ownership
Name
First
Last
Contact Title
Contact Telephone
Contact Email
Business Vertical
*
choose one
Insurance
Medical
Travel
E Commerce
Retail
Hospitality
Property Management
Utilities
Municipalities
Education
Other
What Policy Admin system or CRM do you use?
Insurance Entity Type
Carrier
MGA
Agency
Other
Product(s) - choose all that apply
Property Casualty
Homeowners
Commercial
General Liability
Health
Life
Other
Other Type - Choose all that apply
Fitness
Food
Hobby
Clothing
What States are you licensed in?
If Other, what Business
Business Information
Company Legal Name
*
Business Name DBA (Doing Business As)
*
Business Start Date
*
MM slash DD slash YYYY
Company Website
Please enter the company website URL here
Business Type
*
Sole Proprietor
Partnership
Public Corp.
LLC/LLP
Private Corp
Non-Profit
Government
State Filed
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Location Business Address (No P.O. Box Accepted)
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Legal/Mailing/Billing Address
Same as location address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Federal Tax ID
*
Business Telephone
*
Fax
Number of Locations
*
Customer Service Telephone
*
Customer Service Email
*
Company Information
Company Payment URL
Website address for business, if collecting payments on a website, please provide URL where payments are collected.
Card Holder Descriptor
The 22 character description card holders will see on their credit card statement when a charge from your company appears.
Description of Products/Services Sold
Enter a brief description of the products or services you will be collecting payments for. (Insurance, etc)
Will your business be utilizing separate Trust and Operating accounts?
*
Mark "No" if you will use the same bank account for both fees and deposits.
Mark "Yes" if you will have one bank account on file for deposits and a separate bank account for fees.
No
Yes
Processing Volume
If not yet collecting payments, please estimate expected volume six months from now.
Average Ticket
*
Highest Ticket Amount
*
Monthly Volume
*
Recent Processing Statements
If you are currently processing, please provide three months most recent processing statements.
Drop files here or
Select files
Accepted file types: pdf, png, jpg, gif, Max. file size: 10 MB, Max. files: 3.
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