Getting Appointed

Serve more clients easier, faster, and better

Benefits to getting Appointed

You will need the following documents

*The agency name on the producer agreement and W9 must match agency license.

"*" indicates required fields

Legal Agency Name

DBA Name

FEIN/Tax ID

Entity Type

Agency Type

Physical Address *

Street Address

City

State

ZIP Code

Mailing Address *

Same as Physical Address

Street Address

City

State

ZIP Code

Website

Principal Agent *

First

Last

Principal Agent Phone

Principal Agent Email

Principal Agent License #

Appointment Contact Information same as Principal?

Yes No

Appointment Contact *

First

Last

Appointment Contact Phone

Appointment Contact Email

Book of Business $

Commercial Business %

Personal Business %

Health Business %

Life Business %

Travel Insurance %

Any recent mergers or acquisitions?

Yes No

How did you hear about us?

Does this agency have multiple locations?

Please list companies and MGAs you place business with in order of premium volume:

Carrier/MGA Name #1

Annual Premium Amount #1

12 Month Loss Ratio % #1

Carrier/MGA Name #2

Annual Premium Amount #2

12 Month Loss Ratio % #2

Carrier/MGA Name #3

Annual Premium Amount #3

12 Month Loss Ratio % #3

Supplemental Information:

Have you or anyone in your agency been sued concerning insurance related activities?

Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance?

Has any Errors & Omissions claims been made in the most recent five years against your agency, officers, partners or owners?

Has your agency ever been terminated by a carrier?