Minnesota FAIR Plan

W9 Form for Agents
Fill in the information below and click the "Generate W9 Form" button below to get a completed W9 form.
Business Type: *  
Exempt Status: *  
Phone Number: *    
Fax Number:
MN FAIR Plan website Username:    
  (If you do not have one, enter your email)
Address: *  
Address 2:
Zip: *    
City: *
State: *  
MN License: *  
MN License Expiration Date: *  
EFT Payment Information - THIS IS FOR DEPOSIT ONLY
Account Holder Name: *  
Bank Name: *  
Branch Name: *  
Bank City: *  
Bank State: *  
Bank Zip: *  
Bank Phone Number: *    
 Bank Account Number: *
Help
   
Confirm Account Number: *   
Bank Routing Number: *
Help
     
Confirm Routing Number: *   
Checking/Savings: *  
Personal/Business: *  
Account Numbers:
(Optional)
 
Requester's Name and Address:
(Optional)
   
   
  * Indicates Required Field

**Clicking the button below will generate a completed W9 form.

The W9 needs to be signed and dated then faxed to the MN FAIR Plan at 612-455-0473.
**DO NOT FAX A COPY OF THIS WEB PAGE**
You MUST fax us a copy of the W9 form that is created when you click ‘Show W9 Form’.
Any other forms or print outs will NOT be accepted.



Your account will not be setup or re-activated unless we receive this via fax.**
 
 

Minnesota FAIR Plan
1128 Harmon Pl. Suite 311, Minneapolis, MN 55403-2041

  • 612-338-7584 or 800-524-1640
  • Fax
    • Customer Service/Underwriting: 612-338-4543
    • Account/Claims: 612-455-0473

 

Our office is open to the public:
8:00AM to 4:00PM Monday through Thursday
8:00AM to 12Noon on Friday
Holiday Schedule

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