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To become a UPA appointed agency, please complete the Agency Profile. After completing the profile page, please proceed to Agency Personnel to list agents within your organization whom you want to do business with UPA.

Agency Profile Agency Personnel

Legal Name:

Agency Name:

FEIN/IRS ID:

Physical Address:

City:

State:

Zip Code:

County:

Use my Physical address as my Mailing address:

Mailing Address:

City:

State:

Zip Code:

County:

Telephone Number:

Fax:

Agency Email Address:

Agency Website:

Industry Specialization:

Do you carry E & O Insurance? YesNo

EO Expiration Date:		Limits per Aggregate:
Carrier:

Comments:

Check this box if you are interested on learning more about UPAY-As-You-Go and a representative from CertiPay (payroll provider partner) will contact you shortly.

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User Name:
Password:		Confirmation Password:
Profile Information
First Name:		Last Name:
Job Title:		Role:
Email Address:		Preferred Language
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3665 Bee Ridge Road, Suite 214. Sarasota, Florida 34233. Direct 941.378.7002. Fax 941.309.7600
Unique Program Insurance Agency, CA, is a dba of Unisource Program Administrators.
All rights reserved. © UPA Unisource Program Administrators 2008, 2009, 2010