Agency Sub-Producer Application
Complete the application to be considered for appointment to Shepherd Specialty's program marketplaces.
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Agency Profile
Agency Name
*
DBA Name (if applicable)
*
Primary Agency Email
*
example@example.com
Agency Phone Number
*
Please enter a valid phone number.
Agency Website
Input N/A if you agency does not have a website.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Start Date
*
Any Controlling Entity or Business Affiliation?
*
Yes
No
Controlling Entity or Business Affiliation
States Where Your Agency Conducts Business
*
If agency operates in all states, enter "All states". Otherwise, please list state abbreviations (ex: NY, NJ, etc.)
Contacts
Main Contact Name
*
First Name
Last Name
Main Contact Email
*
example@example.com
Main Contact Phone Number
*
Please enter a valid phone number.
Do you have other agency contacts you'd like to provide?
*
Yes
No
Agency Contacts
*
Agency Production Information
Are you interested in providing agency production information so Shepherd Specialty can better understand your agency and the business you write?
*
Yes
No
Commercial Lines Premium Volume?
$0-$1,000,000
$1,000,001-$5,000,000
$5,000,001-$$10,000,000
$10,000,000+
Personal Lines Premium Volume?
$0-$1,000,000
$1,000,001-$5,000,000
$5,000,001-$10,000,000
$10,000,000+
Commercial Lines: What industries/sectors does your agency focus on?
Restaurants
Professionals (Lawyers, Accountants, etc.)
Manufacturing
Contractors
Health Care
Construction
Towing
Energy (Oil/Gas/Utilities)
Other
N/A
What is most important to you regarding carrier relationships?
Commissions
Ease of Business
Personal Relationships
Support & Training
Fully Online Platform
Competitive Pricing
Instant Binding Ability
Service Center Support
Responsiveness
Other
What % of Agency business is Commercial?
What % of Agency business is placed with Wholesalers/MGAs?
Please provide details on agency specialization in niche markets
What is your greatest product need at this time?
Top 3 Standard Markets
Market Name
Premium Volume
Standard Market 1
Standard Market 2
Standard Market 3
Top 3 E&S Markets
Market Name
Premium Volume
E&S Market 1
E&S Market 2
E&S Market 3
Commercial Distribution of Premium
Premium Volume
Loss Ratio
Auto
General Liability
Workers' Compensation
Property
Specialty Programs
Inland Marine
Wholesale/E&S
W-9
Do you have a completed W-9?
*
Yes
No
FEIN
*
Please upload your completed W-9 below:
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Errors & Omissions (E&O)
E&O Carrier Name
*
E&O Expiration Date
*
-
Month
-
Day
Year
Date
Please upload a copy of your E&O declaration page or COI:
*
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I agree to maintain in-force E&O Coverage while doing business with Shepherd Specialty.
*
Agree
Licenses
Resident License Expiration Date
*
-
Month
-
Day
Year
Date
Please upload all resident and non-resident state licenses below:
*
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Does your agency have any surplus lines licenses?
*
Yes
No
Please upload surplus lines licenses here:
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I agree to maintain active and up-to-date licensing, and provide copies of updated licenses while doing business with Shepherd Specialty.
*
Agree
Payment Information: Electronic Funds Transfer (EFT)
Account Holder
*
Account Type:
*
Checking
Savings
Money Market
Other
Name of Financial Institution
*
Phone Number of Financial Institution
*
Please enter a valid phone number.
Financial Institution Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Number
*
Bank Transit/ABA Number
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please upload a copy of a voided check here:
*
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Agency Agreement
Please review the Agency Contract below:
Have you been convicted of any felonies in the last 5 years?
*
Yes
No
If yes, please describe below:
Have you or the agency faced any disciplinary action from the Department of Insurance?
*
Yes
No
If yes, please describe below:
Agent/Producer
*
Agency Name
Printed Name
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: