Become an Appointed Producer — Agents & Brokers

Agency / Business

Agency / Business Legal Name *

DBA (if any)

Entity Type *

Federal Employer ID Number (EIN)

Required for LLCs, corporations, and partnerships.

Date Business Established

Number of Employees

Website

Owner / Primary Contact

Full Name (owner / principal) *

Title / Role *

Direct Phone *

Fax

Email *

Agency Location Address

Street Address *

City *

State *

ZIP *

Mailing address is the same as location

Licensing

National Producer Number (NPN) *

Primary State of Licensure *

License Number *

License Expiration *

Additional Licensed State(s)

Additional License Number(s)

Errors & Omissions (E&O)

E&O Carrier

Policy Number

Expiration Date

Per-Claim Limit

Aggregate Limit

Book of Business

Lines of Business Written

Niche / Target Industries

Estimated Annual Premium (whole agency)

Additional Users to Appoint (optional)

Sign the agreement

Your signature applies to the Producer Agreement, Personal Guaranty, Information Form, Commission Schedule, and W-9 as one electronically signed package.

Draw your signature here

Type your full legal name *

By typing my name and checking this box, I adopt this as my electronic signature and affirm that it is the legal equivalent of my handwritten signature under the federal ESIGN Act (15 U.S.C. §7001) and applicable state UETA. I certify that the statements in this document are true and accurate to the best of my knowledge.

Get appointed and start placing business

No volume commitments

Wholesale and specialty markets

Online applications

Signed in one sitting