DOES MAILING ADDRESS THE SAME AS PHYSICAL ADDRESS? *
Please list all of the agency principals
HAS ANY PRINCIPAL, PARTNER OR OFFICER OF YOUR OFFICE EVER BEEN CHARGED OR CONVICTED OF FRAUD AND/OR A FELONY? *
HAS YOUR INSURANCE LICENSE EVER BEEN SUSPENDED AND/OR REVOKED, OR HAVE YOU EVER BEEN FINED BY AN INSURANCE DEPARTMENT? *
We often work with agencies that have multiple locations as well as multiple agents/brokers and support staff members. Based on your business operation you are able to have multiple locations and multiple users per location. Please note that agency administrator can be reassign at any time.
For an agency to be appointed, the following documents are REQUIRED :
Current copy of E&O showing limits of at least 1 million aggregate. If the agency is a corporation, the E&O needs to show that the corporation is covered under the policy.
Current copy agency/agent license for the state of residence. For Florida agents, both the agent and agency license must be submitted. Please also submit any other licenses the agency may hold in any other states.
Current W-9 form – Please complete and sign. Make sure to include legal name and dba, if any. The first line of the form cannot be left blank.
I hereby certify that I have reviewed this application and the information is true, correct and complete. If any information given to obtain or maintain an appointment is found to be incorrect or incomplete, it will be grounds for rejecting this application or for termination of my appointment in the sole discretion of the insurance company.
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