Agency | Agent Application

Agency | Agent Application
Name of Agency*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Agency Structure*

CorporationLLCPartnershipSole ProprietorOther
Is this a branch office?*

YesNo
Date Established*
FEIN
If you are a sole proprietor, please provide your SSN
If you are a Sole Proprietor, please provide your SSN
Please list names of all current principals and owners of the Agency and their length of time in this capacity.
Has your company ever used another name?*

YesNo
Prior Names
Approximately how much aviation insurance premium does your agency handle?*
Will the Agency be brokering Aviation/Aircraft Business for other agents?*

YesNo
Please list names of licensed agents who will be producing aviation/aircraft business.
Phone Number*

Area CodePhone Number
E-mail*
Signature*

First NameLast Name
Should be Empty: