Branch Appointment Form
Agency Name
*
Agency Principal Name
*
First Name
Last Name
Agency Principal's Email
*
Agency Email Address if Different
Agency Principal Phone Number
*
Agency Phone Number if Different
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website URL
*
Agency NPN
*
Agent/Producer NPN
*
State Where You Are Located
*
State Where You Want to Write Business
*
What Rater do you use?
*
Total Personal Lines Premium
*
Average Personal Lines Quotes Per Month
*
Do you agree to complete 40 quotes in the first 45 days?
*
Yes
No
Please acknowledge that you understand that Branch Insurance is not available in a comparative rater and through this acknowledgement your agency guarantees that Branch's industry leading, bundle technology will be utilized outside of the comparative rater for production
*
I acknowledge
I do not acknowledge
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