The AGU San Francisco Limited Accident & Sickness Indemnity Plan

Support For Brokers

AGU distributes the products it administers exclusively through independent agents and brokers. This section provides information and tools for our distribution partners. The AGU San Francisco Limited Accident & Sickness Indemnity Plan addresses a unique need and situation requiring particular expertise. To assist brokers and facilitate marketing and sales, AGU will work with brokers and coordinate efforts to present the AGU San Francisco Limited Accident & Sickness Indemnity Plan compliance solution to businesses subject to the Health Care Security Ordinance.

Here you can:

  • Personalize the printable summary to include your client’s name and your contact information;
  • Personalize a copy of the Group Application with your information in the broker section;
  • View and print the new case submission checklist;
  • Obtain appointment paperwork and instructions; and
  • Print employee wavier forms in three languages for your clients.

Expand Each Section Below for details

Large Employer Plans (100+ Employees) Medium-Sized Employer Plans (51-99*)
* Employers With 20-49 Employees Are Not Eligible For The AGU San Francisco Limited Accident & Sickness Indemnity Plan


The Number Of Employees Is Determined By The Total Number Of Employees Worldwide Not The Number In San Francisco.
Employers With Fewer Than 20 Employees And Non-Profit Organizations With Fewer Than 50 Employees Are Exempt From The Ordinance
Large Employer Plans (100+ Employees) Medium-Sized Employer Plans (51-99)
Complete the form on-line using the mouse or tab-key to move between fields. Print the finished form to deliver to your client for signature.

Pressing the Reset Button will clear all fields in the form.
Mail or Fax To:
Affinity Group Underwriters, Inc.
Attn: Lori Mills
4510 Cox Road
Suite 111
Glen Allen, VA 23060
FAX: (804) 273-9989

Group Application signed by the employer


List of employees enrolling1 on the policy effective date, including:

  • First Name
  • Middle Initial
  • Last Name
  • Social Security Number (if this is not provided, we will assign a substitute number for claims purposes)
  • Date Of Birth
  • Gender
  • Date of Hire
  • Street Address
  • City
  • State
  • Zip Code
  • Home Telephone Number
  • Benefit Class 2 - assigned by the employer based on hours worked in the previous 90 days. In general, the benefit class to which the employee is assigned will remain the same until the next policy anniversary date unless an off-anniversary change is requested by the employer and approved by AGU.

Agent Appointment Paperwork

(if not already appointed) – note: forms and instructions are available in the Appointment section below

  1 Initial employee enrollment data can be provided:
  • For groups with fewer than 200 employees enrolling – in an electronic format (EXCEL spreadsheet or fixed length ascii file);
  • For groups with 200+ employees enrolling - via electronic file transfer using ascii fixed length files (contact AGU for a document which explains the field details).
2 To determine to which class an employee should be assigned for benefits, take the hours worked over the previous 90 days and divide by 12.86 (90 days divided by 7 days):
  • Class One - Part-time employees working 8 -19 hours per week
  • Class Two - Part-time employees working 20-39 hours per week
  • Class Three - Full-time employees working 40+ hours per week
Refer to the Eligibility on the website for more information regarding which employees can be covered under this plan.

For information about enrollment procedures after the policy effective date, additions and terminations and monthly premium self-reporting, see Administration on the website or contact AGU.
In most states, appointment paper work should be submitted along with the first group application. The exceptions are: Delaware, DC, Georgia, Montana, New Mexico, North Carolina and Pennsylvania where pre-appointment is required by law.
  In order to be appointed and receive commissions, an agency must submit the following items
  1. Completed Licensing Information Form. On page 1, complete the Sub-Producer Information section and the Form Completed By section. On page 2, complete the “Individual License Data Needed” section for each agent with the agency that wishes to be appointed. Important! The agent who signs the Group Application, along with the agency, must be licensed and appointed in the state where the group is located. (click here for Licensing Information Form).
  2. Copies of current licenses for the agency and agent in all states where marketing will occur;
  3. Copy of current E&O declaration page or Certificate of Insurance (if the agent is not an employee or officer/owner of the agency, a separate verification from the E&O carrier listing the agent is needed).
  4. completed W-9 form (click here for W-9 form).
  5. Check payable to ACE American Insurance Company for the total amount of state appointment fees for the agency and agent (click here for appointment fee listing by state)
If there is no agency, please provide the above information for the agent. Page 1 & 2 of the Licensing Information Form should be completed with the agent information.

Under no circumstances will compensation be paid to any entity not licensed in a state where this insurance is solicited. Compensation will only be paid when the appropriate licensing and appointment requirements have been completed.

Renewal fees for appointments are paid by ACE USA.
  All appointment questions and/or paperwork should be addressed to:

Charlotte Cutright

Affinity Group Underwriters
4510 Cox Road, Ste. 111
Glen Allen, VA 23060
Toll-free: 877-673-9797
Fax: 804-273-9989