Qualitas Premier Appointment Request

Appointment Request

Please complete all sections of this questionnaire
General Information
Legal Name
DBA
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Agency is a

Other
Date Agency Established

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Employees and Contact Information
Agency Personnel - Key Employees
Contact in Accounting
Contact in Customer Service
Number of Employees
How Many are Licensed?
Any part-time Employees? If No, enter 0.
Have you or anyone in your agency been sued concerning insurance related activities?
If Yes, please explain
Has you, your employees, or your agency been disciplined by ANY State agency or Department of Insurance?
If Yes, please explain
Do you carry Error & Omissions Insurance? - If "No" we will not approve an appointment.

Carriers and/or GAs
List Principal Companies (Carriers/GAs) you have Agent/Broker Agreements with, in order of premium volume
Must include Loss Runs for the past 3 years directly from the carrier or GA to support the loss ratio provided above.
Current Year Written Premium
Written Premium from last year
Written Premium from 2 years ago

Documents and Signature
Please upload copies of the following as part of your applications:
1. Individual Brokers and Agency License(s)
2. Errors and Omissions Dec Page (Carrier must be "A" Rated of better")
3. Must include Loss Runs for the past 3 years directly from the carrier or GA to support the loss ratio provided in the "Carriers and/or GAs" section.
File Upload

Cancelof
Your Name
Your Title
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Appointment Request