Appointment Request (New State for an Existing Contract) rev 3-30-2022

State Appointment Form
Name of Person Making the Request

First NameLast Name
Email Address of Person Making the Request
example@example.com
Request Date

MonthDayYear
Date
Is this appointment request for you or someone else?
Name of Agent Needing State Appointment

First NameLast Name
Please list the carrier(s) the agent needs to be appointed in.
Select the state(s) that the agent needs to be appointed in. *Please note that some carriers charge appointment fees. By requesting to be appointed you acknowledge that you are aware of this and have notified the agent of, and they understand and agree to any potential fees that may be imposed.
Does the agent have pending business to submit? (TSS EMPLOYEES ONLY)
Please upload a copy of the agent's license for each state appointment being requested.

Cancelof
Please sign below to acknowledge that you are requesting the state appointment(s) and that you or your agent agree to the appointment fees that may be due.
Should be Empty:

State Appointment Form