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 Fax 253-216-8289
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  • New Customer Agreement
ALL portions of this New Account Agreement must be complete and accurate or your Agreement will not be accepted by the issuing company

    New Customer Agreement

    Antik LLC will use this General New Account Agreement with its appointed and affiliated insurance providers

    1) Account Profile

    2) Proposed Insureds

    3) Employer Agreement and Disclosure
    -Upon approval, the account holder (your company) agrees to establish a voluntary insurance program for the benefit of it's employees/members.  For each employee/member who executes a payroll deduction request, we will withhold the amount authorized.  We will forward this money to the issuing provider upon notice of the premium due from each employee/member.
    -We may, upon written notice, discontinue our participation in this month-to-month insurance program.  In such event, the continued payment of premiums will be a matter directly between each employee/member and the issuing provider.
    ​-We assume no responsibility for forwarding premiums from anyone other than current employees/members.
    -We understand that the provider does not disclose personal information about the employees/members to companies/organizations not affiliated with the insurance provider.
    -For group insurance coverage, we may receive paper versions of the certificates and accompanying notices.  However, we instead request that we receive electronic delivery, where applicable.
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Antik LLC
15 Oregon Ave #207
Tacoma WA 98409