Majestic Online Broker Registration

Registration Information
We require the following information about authorized Users of the Site. Once approved, your authorized User name(s) and password(s) will be sent to you by e-mail. Please complete the following information. (required fields are indicated by *):

* Agency/Company Name:

* Broker Code:

* Broker Representative Name:
	First Name	M.I.	Last Name

* Broker Representative Title:

* Phone Number:

- Ext

* E-mail Address:

* Street Address:

* City

*State: *Zip:

* Access Level: (select one)
Allow Access to All Polices

Limit Access to Specific Policies Only:
Enter policy number (s):	, ,

* Who will supervise the employee(s) who have access to the Site? (select one)

I will

The following Representative will: (please complete the information below)

* Representative Name:
	First Name	M.I.	Last Name

* Phone Number:

- Ext

* Who will notify Majestic when User access should be revoked? (select one)

I will

The following Representative will: (please complete the information below)

* Representative Name:
	First Name	M.I.	Last Name

* Phone Number:

- Ext

I would like to sign up this User: (please complete the information below)

* Broker Representative Name:
	First Name	M.I.	Last Name

* Broker Representative Title:

* Phone Number:

- Ext

* E-mail Address:

* Access Level: select one)
Allow Access to All Policies:

Limit Access to Specific Policies Only:
Enter policy number (s):	, ,

I would like to sign up this User: (please complete the information below)

* Broker Representative Name:
	First Name	M.I.	Last Name

* Broker Representative Title:

* Phone Number:

- Ext

* E-mail Address:

* Access Level: select one)
Allow Access to All Policies:

Limit Access to Specific Policies Only:
Enter policy number (s):	, ,

I would like to sign up this User: (please complete the information below)

* Broker Representative Name:
	First Name	M.I.	Last Name

* Broker Representative Title:

* Phone Number:

- Ext

* E-mail Address:

* Access Level: select one)
Allow Access to All Policies:

Limit Access to Specific Policies Only:
Enter policy number (s):	, ,

Legal Terms and Conditions
Access to and use of the Site by authorized Users is subject to the Legal Terms and Conditions posted on the Site. You must read the Legal and Conditions, together with Majestic's Privacy Statement, and require that all authorized Users do the same.

After reviewing this form, the Legal Terms and Conditions and the Privacy Statement, please have the acknowledgment below digitally signed by your authorized representative to signify your acceptance of the same. Click "I Agree" to submit the completed and signed form to Majestic Insurance. Or, if you prefer, please print a hard copy of this form and have the acknowledgment below signed by your authorized representative to signify your acceptance of the same. The completed and signed form should be faxed to:

Deanna Ikeda
Web User Administration, Majestic Insurance
415.777.5997 fax

Acknowledgment (this section must be completed to register for e-Majestic)
I, , acknowledge that I am the authorized representative of the Broker named above; that I have read and understand the foregoing contents of this form, the Legal Terms and Conditions and Majestic's Privacy Statement; and that the Broker accepts and agrees to be bound by the same, including future changes.

(Digital Signature)

(Title)

Date

Your registration process will not be completed until you press the "I Agree" button.
If you change your mind for any reason, press the "I Disagree" button.