MVP Test – Emergency Advantage

MVP Vendor Registration Form:

Please review the form below and ensure that all documents are available prior to submitting. Required fields are followed by an asterisk (*) and you will be alerted prior to submitting the form if any required fields are not populated. Leave any optional fields for which you don’t have information with “- Select -” in the drop-down. For questions & concerns, please call 888-852-4485 ext. 4.

Company Information:	*required field
Company Name*
Address1*
Address2
City*
State*
Zip*
Website
Additional Certification (optional)
General Company Information:
Year Incorporated
Annual Revenue
Number of Employees
Bond Capacity	(Enter number)
Professional Liability Insurance
Service Category Selections:
Service Category 1*
Service Category 2*
Service Category 3*
Description of Services*:
Primary Contact Information:
Primary Contact*
Title
Office Phone*
Cell Phone
Email*
Accounting Contact Information:
Accounting Contact Name
Office Phone
Office Fax
Address1
Address2
City
State
Zip
Company Business Information:
Tax ID (EIN or SSN)*
W-9 Attachment*
General Liability Insurance Certificate*
	* Please include a copy of your declarations page provided by your insurance carrier. The required insurance certificate must be issued by an insurance company that is properly licensed, duly authorized business in the State of Florida or another state, and meets minimum qualifications based on the most current edition of A.M. Best’s Insurance Guide.
Workers Comp. Certification*
Auto Insurance Certificate*
By clicking the “Submit” button below, you are authorizing Synergy ID LLC to validate your information with Local &/or State Records. Your information will also be uploaded into simpliCity software which manages the FMIT Vendor Database.