PROVIDER MEMBERSHIP LEVEL REQUIREMENTS Bold Fields Are Required First Name: Last Name: Title: Assgnmnts/Mo: Company: E-Mail: Phone1: Type1: Office Phone Mobile Home Phone Fax Pager Phone2: Type2: Office Phone Mobile Home Phone Fax Pager Address1: Address2: City: State: 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 Zip:             Type of Assignments (Check all that apply): Premium Audits:   Loss Surveys: Personal Lines:  Other:  Solutions of Interest (Check all that apply): PWAdministrator: PWAuditor: PWReviewer:PWMail: PWPhone: PWWeb: PWManage: LWAdministrator: LWSurvey: LWReviewer:  LWWeb: LWManage: Territories Needing Service: (Please be specific, such as City, State, Zip, and/or Metropolitan Area and separate with a comma.) EXAMPLE1:  (Dallas, Irving, Plano)  EXAMPLE2:  (TX, CA) EXAMPLE3:  (75052, 76015, 94512)  EXAMPLE4: (DFW) Enter the above code exactly as it appears:

ENTERPRISE SOLUTIONS PROVIDED BY PremiumWare, Inc. PremiumWare Administrator: Provides a user interface for Managing, Reporting, Billing, while automating Auditor and Territory Assignment. PremiumWare Reviewer: Provides a user interface for Managing, Tracking, and Assigning of complete audits for review and correction. PremiumWare Phone: Provides a user interface for Managing, Tracking, and Assigning Phone Audits reducing the bulk distribution of policies. PremiumWare Manage: Provides a browser-based interactive viewer allowing for Inventory Look-Up and Progress Note editing. PremiumWare Auditor: Provides individual Audit Inventory management and scheduling along with electronic reciept and transmittal of completed audits. PremiumWare Mail: Provides automated tracking, follow-up, audit escalation, and Optical Character Recognition (OCR) input of policy data using Desktop Scanner technology. PremiumWare Web: Provides a browser-based interactive viewer allowing for real time reporting of Audit Status and Outstanding Inventory. LossWare Administrator: Provides a user interface for Managing, Reporting, Billing, while automating Engineer and Territory Assignment. LossWare Reviewer: Provides a user interface for Managing, Tracking, and Assigning of complete audits for review and correction. LossWare Manage: Provides a browser-based interactive viewer allowing for Inventory Look-Up and Progress Note editing. LossWare Survey: Provides individual Assignment Inventory management and scheduling along with electronic reciept and transmittal of completed assignments. LossWare Web: Provides a browser-based interactive viewer allowing for real time reporting of Survey Status and Outstanding Inventory.