Agency Appointment Information
*Please fill in the following information to the best of your ability. If you are not able to provide certain info, leave it blank and we will reach out to correct point of contact to acquire it.
Agency Name
*
DBA Name (if applicable)
Primary Agency Email
*
example@example.com
Agency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Website
Input N/A if your agency does not have a website.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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.)
Back
Next
Contacts
Main Contact Name
*
First Name
Last Name
Main Contact Email
*
example@example.com
Main Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have other agency contacts you'd like to provide?
Yes
No
Agency Contacts
Back
Next
Documents Required for Appointment
Please upload a copy of your E&O declaration page or COI:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
W-9
Do you have a completed W-9?
Yes
No
Please upload your completed W-9 below:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Licenses
Please Upload a copy of the Agency’s State Insurance License:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Individual Producer State Insurance License:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does your agency have any surplus lines licenses?
Yes
No
Please upload surplus lines licenses here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Agency Production Questionnaire (Optional)
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
Rows
Market Name
Premium Volume
Standard Market 1
Standard Market 2
Standard Market 3
Top 3 E&S Markets
Rows
Market Name
Premium Volume
E&S Market 1
E&S Market 2
E&S Market 3
Commercial Distribution of Premium
Rows
Premium Volume
Loss Ratio
Auto
General Liability
Workers' Compensation
Property
Specialty Programs
Inland Marine
Wholesale/E&S
Back
Next
Payment Information: Electronic Funds Transfer (EFT)
This information can be provided after your first Bind with Shepherd Specialty if preferred.
Account Holder
Account Type:
Checking
Savings
Money Market
Other
Name of Financial Institution
Phone Number of Financial Institution
Please enter a valid phone number.
Format: (000) 000-0000.
Financial Institution Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Number
Bank Transit/ABA Number
Date
-
Month
-
Day
Year
Date
Back
Next
Legal Questions
Have you, or any other agents that will be appointed from your agency, been convicted of any felonies within 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:
Signature
Printed Name
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: