Become an Agent


General Agency Information

Name of Agency:
Physical Address:
County:
City:
State:
Zip:
Is the physical address the same as the mailing address?
Telephone:
Fax:
Cell Phone:
Email Address:
Company Website:

Agency Background

Year agency was established:
Error & Omissions Carrier:
E & O Limits:
E & O Effective Date:
Tax ID#:
Legal Entity of Agency:
How did you hear about us?

Agency Commercial Lines Premium For Last 3 Years

2017 Volume ($)
2016 Volume ($)
2015 Volume ($)

Principal Personnel Information

Name 220 License # Years with Agency

List Companies You Represent

Carrier Year Licensed Premium Volume ($)
Does agency specialize in select trade group programs? (Printers, gas stations, restaurants, etc):
Does agency actively solicit commercial lines business?

Financial Information

List companies with whom you are on account current basis:
Have you ever been terminated by a company for failure to remit premium payments?:
Have any principal and/or stockholder of agency ever declared bankruptcy?:
Name of person completing application:
Position with agency:
Narrative (Additional information about the agency that you would like to highlight):