SmartChoice: Agency Program Application

Agency Application
Agency Name*
Agency NPN*
Please verify here: https://nipr.com/help/look-up-your-npn
Your Name*

First NameLast Name
Agent NPN*
Please verify here: https://nipr.com/help/look-up-your-npn
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address (we are not accepting CA appointments)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
About Your Business
Which states are you licensed to operate in? (Check all that apply)

ArizonaCaliforniaColoradoConnecticutWashington D.C.GeorgiaIllinoisIndianaIowaMarylandMassachusettsMichiganMissouriNevadaNew JerseyNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandTennesseeTexasVirginiaWisconsinOther
Do you focus in any of the below areas? (Check all that apply)

San Francisco - Oakland - San JoseSan DiegoLos Angeles - Orange CountySanta Barbara-San Luis ObispoMonterey-SalinasDallas-Fort WorthPhoenix - TucsonHoustonAustinSan AntonioNew York City MetroChicago / Cook CountyOther areas, not the ones listed.
Which Rater do you use?*

EZLynxPL RaterITC TurboraterAppliedNo RaterOther
What Rater do you use?
Total NEW homeowners premium written in the last 12 months*
$ Premium (e.g. $500,000)
On average, how many homes do you quote per month?*
# of HO quotes per month
How many home policies did you sell last month?*
# of HO policies sold per month
Please list your average homeowners loss ratio for the past 3 years*
Loss ratio %
Where do you write most of your home business?*

Cities (urban)Burbs (suburban)Country (rural)
How many producers work in your agency?*
Please list your top 3 home insurance carriers*
Carrier Names
Who is your territory manager*
Name of territory manager
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