CARCO Pre-Insurance Inspection System

CARCO Pre-Insurance Inspection System

OPTIS ENROLLMENT FORM

If you are an existing client, do not use this form to add additional users. Please use the Administration function in OPTIS, or contact CARCO for assistance.

SECTION A - BUSINESS INFORMATION

Business Name: Valid Please provide a valid business nameMinimum number of characters not met.Exceeded maximum number of characters.

Street Address: Valid Please provide a valid street addressMinimum number of characters not met.

Street Address 2: (optional)

City:   State:   Zip Code:

City,State and Zip Code invalid

Fax: Valid Invalid format. (optional)

SECTION B - PRINCIPAL'S INFORMATION

Principal's Name: Valid Please provide a valid Principal Name

Principal's E-Mail Address: Valid Please provide a valid email address invalid format

Principal's Phone#: Valid A value is required.Invalid format. Ext.

SECTION C - MAIN CONTACT Check here if different than principal

This person, if different than principal, will be the contact for invoices, general communications, account administration, etc.:

Name: Valid please enter name

E-Mail Address: Valid please enter email Invalid format.

Phone#: Valid please enter phone numberInvalid format. Ext.

SECTION D - INSPECTION NOTIFICATION

Each individual who orders an inspection will receive an order confirmation and reminder notice after 15 and 30 days if the inspection has not been received by CARCO.

You will also receive a summary of all inspections processed by CARCO on a daily basis. This summary statement should be sent to the following individual:

Principal   Main   Other   Please make a selection.

Name:
Valid
You checked "other" - please enter name
E-Mail Address:
Valid
You checked "other" - please enter emailInvalid email format

SECTION E - CARRIERS REPRESENTED

Carriers Represented:

Inspection Accounts Needed in:
FL   NY   NJ   MA   RI Valid Please select at least one state

Other:

Estimated Monthly Volume:

Additional contacts that will need access codes:
Please note, all inspection orders placed by the contacts added below will be billed to the credit card below.

SECTION F - CREDIT CARD INFORMATION

Credit Card Type:
Valid Please select credit card type

Card Holder Name:
Valid Please provide a card holder name

Credit Card Number:
Valid Please provide a credit card numberInvalid format.

Expiration Date:
Please select month.Expiration date must be 2 moths from today Please select year.

Authorization: Valid Authorization is required.
I hereby authorize CARCO Group, Inc. to charge the indicated credit card for all future inspections performed by CARCO, and further state that I am the authorized cardholder for the above credit card. I also agree not to file hostile chargeback without notifying CARCO ahead of time in writing and allowing for resolution.