New Producer Application Form

Producer Application Form

Please complete the form, upload relevant documents if available, and agree to the terms by signing and dating.
Agency Information
Agency Name
DBA, if applicable
** If applicable
# of Employees:
Is your agency owned by a Parent Company?
Parent Company Name
**If applicable
Location Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address same as Location Address?
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Website
When was Agency Established?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personnel/Contacts
Primary Contact

First NameLast Name
Primary Contact Email
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please upload up to date employee roster and contact info, if available.

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Agency Book Information
What lines of business does you agency currently focus on? (Check all that apply)
Other Lines:
What other wholesalers/MGAs do you work with?
Total Agency Commercial Premium
Agency Banking Information
Primary Accounting Contact

First NameLast Name
Primary Accounting Contact Email
example@example.com
Bill to Parent Company?
Billing Address same as Mailing Address?
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Bank for Trust Account
Address of Bank

Street Address

Street Address Line 2

CityState

Postal / Zip Code
W-9/Tax Information
W-9 Form

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Name (as shown on your income tax return)
Business Name/Disregarded Entity name, if different from prior question
Check appropriate box for federal tax classification of the name entered above
Employer Identification Number
Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance/Licenses
Do you carry Errors & Omissions Insurance? (Sand Harbor Specialty requires minimum limits of $1,000,000 to appoint agency and transact business)
Please upload your company's E&O Declarations page or Certificate of Insurance

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Do you carry Cyber Insurance? (Sand Harbor Specialty requires minimum limits of $1,000,000 to appoint agency and transact business)
Please upload your company's Cyber Declarations page or Certificate of Insurance

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Please upload all applicable P&C Agent and Agency Licenses

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Have you or any owner or officer of your agency, in the past 5 years been the subject of disciplinary action by any state Department of Insurance or other regulatory agency?
Contract
Producer shall execute this Agreement and provide original signatures to Sand Harbor Specialty without modification to the Agreement. The effective date of this Agreement shall be the date when this Agreement becomes fully executed.

Producer and Sand Harbor Specialty have read and understand all the terms and conditions of this Agreement. By their signature below, each voluntary agrees to be bound by the terms and conditions herein.

Producer also grants Sand Harbor Specialty consent to send unsolicited commercial communications (including but not limited to: quotes, applications, policy reminders such as cancellations or expirations, or invitations to special events) via email to the email addresses provided to Sand Harbor.
Signature (Required)
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Producer Application Form

Agency Information

Personnel/Contacts

Agency Book Information

Agency Banking Information

W-9/Tax Information

Insurance/Licenses

Contract