Become an Agent

Please provide as much information possible on this application. This information will be kept confidential and will be used for internal purposes only.

Producer Profile

Agency Name

Mailing Address

Street or PO Box

City

State

Zip

Is your physical address different from your mailing address?

Yes

Physical Address

Street

City

State

Zip

Phone

Fax

Email Address

Website URL

You are a/an

List Your Top 5 Companies and MGAs/Surplus Lines Brokers

Companies

MGA/Surplus Lines Brokers

What percentage of these lines of business is your Agency currently writing?

% Commercial

% Personal

% Other

Agency volume for the past 3 years beginning with the most recent year:

Last Year $

2 years ago $

3 years ago $

Of the above listed volume - what % is Commericial E&S or Surplus Lines Business?

Number of years in business:

years

Please List the Key Personnel in your Office Including, Owners, CEO, Accounting, Marketing, CSRs & Administration

Name

Title

Email

Phone Extension

Please List (in order of importance) the Types of Risks You Specialize in:

Policies, Endorsements, and Miscellaneous Documents

Will you accept policies, endorsements, and miscellaneous documents via email?

Yes

Would you prefer a call from our marketing team?

Yes

Specify which policies and give details below:

Form Completed by:

Referred by:

Additional Comments

Upload Agency License

Upload E&O

Upload W9 (download form)

Please click on the "Submit Request" button to send your Producer Profile. One of our representatives will respond to your submission as soon as possible