Agency Owner Name:
*
Agency Name:
*
Agency Developer (if applicable):
Agency Owner Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Owner Cell Phone:
Agency Owner Business Phone:
Agency Owner Email Address:
*
Agency Owner Date of Birth:
Agency Owner SS#:
State License #:
Please upload license for each state you with to write business in.
Browse Files
Cancel
of
What states do you want to write business in?
What Wholesalers are you currently appointed with? If any.
What carriers are you directly appointed with? If any.
Have agency owners ever filed an E&O claim? If so, please attach short explanation.
NPN:
Agency’s Tax ID (If you have one):
Do agency owners have a spouse/family member that is a licensed agent? If yes, please list name
Have agency owners marketed or operated an agency under a trade or business name in past? If yes, please list:
Do agency owners have any non-competes? If yes, with who?
List the names of the Agency owners
Will you actively participate in the management and day to day operations of your agency?
Will you be the agent of record? If not, who will be?
If you are not the agent of record, what experience does the intended agent of record have?
Have any of the agency owners ever had a fine or disciplinary action from a state department insurance?
Have any of the agency owners filed for bankruptcy?
Have any of agency’s contracts or appointments been cancelled or terminated within the last five years?
Have agency owners or anyone in your agency ever plead guilty or no contest to, or have been convicted of a felony or misdemeanor?
What is your annual goal for premium growth?
How did you hear about us?
Submit
Should be Empty: