Broker Intake Form

Matterhorn National Producer Agreement Application

We appreciate you taking the time to complete!
In order to obtain/maintain an appointment with Matterhorn Insurance Group, we require the following*
Please add your W9, E&O COI, and Employee Dishonesty COI here*

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General Information
Legal Name*
DBA Name*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Website
Which States are you Currently Licensed to Conduct Business In?*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
NIPR #
State P&C License # (if different than NIPR #)
Please upload a copy of your P&C and A&H licenses

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We are -*

Single LocationMulti Location
Provide location list
Background Information
Year Established*
Does your agency operate solely (100%) as a retailer*

YesNo
Operations
Principal Contact Name*
Principal Contact Phone Number*
Please enter a valid phone number.
Principal Contact Email*
example@example.com
Accounting Contact Name*
Accounting Contact Phone Number*
Please enter a valid phone number.
Accounting Contact Email*
example@example.com
If you have a single email address you would like us to send policy documents to, please provide
Accounting
Premium Account Bank Name*
Premium Account Name*
Premium Account Number*
Premium ACH Routing Number*
Premium Wire Routing Number*
If you have multiple locations and DO NOT have centralized accounting, please upload a file with premium account information (see above), contact name and email address for each location

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Due Diligence
Has any principal or employee ever been charged with or convicted of a crime?*

YesNo
Please explain
Has any license pertaining to any type of insurance related activity and held by any principal employee ever been revoked, suspended, or withdrawn by action of any regulatory authority?*

YesNo
Please explain
The undersigned is an authorized representative that hereby declares that the information given above is true, complete, and accurate with no misrepresentations, or any other concealment of fact*

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Name*
Title*
Date*

MonthDayYear
Date
Signature*

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Matterhorn National Producer Agreement Application

General Information

Background Information

Operations

Accounting

Due Diligence