Agency Application

Agency Application
Agency Information
Agency Name*
DBA (if applicable)
Agency Primary Email*
example@example.com
Agency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Agency Website*
If your agency does not have a website, please put N/A.
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Entity Type*

CorporationLLCPartnershipSole ProprietorshipOther
Any controlling Entity or Business Affiliation?*

NoYes
Controlling Entity or Business Affiliation*
What year did the agency start?*
Please select all states the Agency conducts business*

ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAll States
Contacts
Main Contact Name*

First NameLast Name
Main Contact Email*
example@example.com
Main Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have other agency contacts you would like to provide? This will give them access to Eastern's Agent Portal for online quoting/binding.*

YesNo
Accounting/Administrator Contact Name*

First NameLast Name
Accounting/Administrator Contact Email*
example@example.com
Accounting/Administrator Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Agency Contacts*
Agency Production
Would you like to provide Agency Production information so Eastern can better understand your agency and the business you write?

YesNo
What is your Agency's Premium Volume in Commercial Lines?

$0-$1,000,000$1,000,001-$5,000,000$5,000,001-$10,000,000$10,000,000+
What is your Agency's Premium Volume in Personal Lines?

$0-$1,000,000$1,000,001-$5,000,000$5,000,001-$10,000,000$10,000,000+
What classes of Commercial Lines does your Agency write?

Auto Repair/ServiceContractorsHealth CareProfessionals (Accountants, Lawyers, etc.)RestaurantsTowingTruckingN/AOther
What are the most important aspects in a carrier partnership?

100% Online PlatformAbility to Instant Issue PoliciesCommissionsCompetitive PrivingComplete Service Center Support for CustomersEase of Doing BusinessPersonal RelationshipsSupport & TrainingOther
What % of your Agency's business is commercial?
What % of your Agency's business is with Wholesalers/MGAs?
Please provide any details on agency specialization in niche markets
What is your agency's greatest product need at this time?

W-9
Do you have a completed W-9 (Oct. 2018 version)?*

YesNo
FEIN*
Please complete and download the W-9 Oct. 2018 version below:

Oct. 2018 W-9
Please upload your completed W-9 (Oct. 2018 version) below:*

Cancelof
Errors & Omissions (E&O)
E&O Carrier Name*
E&O Expiration Date*

MonthDayYear
Date
Please upload a copy of your E&O declaration page or COI below:*

Cancelof
Licenses
Resident License Expiration Date*

MonthDayYear
Date
Please upload all resident and non-resident state licenses below:*

Cancelof
Does your agency have any Surplus Lines licenses?*

YesNo
Please upload all Surplus Lines licenses below:*

Cancelof
Electronic Funds Transfer (EFT)
Account Holder*
Account Type:*

CheckingSavingsMoney MarketOther
Financial Institution Name*
Financial Institution Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Financial Institution Address*

Street Address

Street Address Line 2

CityState

Zip Code
Account Number*
Bank Transit/ABA Number*
Signature*
Date*

MonthDayYear
Date
Please upload a copy of a voided check below:*

Cancelof
Agency Agreement
Please review the Agency Agreement below:
Have you been convicted of any felonies in the last 5 years?*

YesNo
Please provide details on the felony(ies):*
Have you or your agency had any disciplinary action from the Department of Insurance?*

YesNo
Please provide details on the DOI action:*
Sub-Producer*
SIGNATURE*
Printed Name*
Date*

MonthDayYear
Date
Referral Source*
Are you interested in an Eastern Underwriting onboarding Webinar?*

YesNo
Does your Agency want access to biBerk?*

YesNo
By completing this application, your agency will be opted-in to email communication on our product offerings, new carriers, agent incentives, and more.
Nexsure Portal Login

Yes
SUBPRODUCER ID NUMBER EUM
Should be Empty:

Rows	Market Name	Premium Volume
Standard Market 1
Standard Market 2

Rows	Market Name	Premium Volume
E&S Market 1
E&S Market 2

Rows	Commercial Premiums	Loss Ratio
Automobile
General Liability
Inland Marine
Property
Specialty Programs
Workers’ Compensation
Wholesale/E&S

Agency Application

Agency Information

Contacts

Agency Production

W-9

Errors & Omissions (E&O)

Licenses

Electronic Funds Transfer (EFT)

Agency Agreement