Agency Sub-Producer Application
Complete the application to become appointed with Shepherd Specialty's exclusive marketplaces.
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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.
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.)
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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
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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
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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
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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
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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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Copy of 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: