Accident Insurance Company Agency Application
Agency Information
Agency Name
*
State of Formation
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Agency Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address same as Physical Address?
*
Yes
No
Agency Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Agency Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Email Address
*
example@example.com
Agency Entity Type
*
Please Select
LLC
Corporation
Sole Proprietor
General Partnership
Other
Agency Contacts
Primary Contacts
*
Rows
Contact First & Last Name
Phone
Email
Primary Contact
Accounting Contact
Support Staff Contact
Number of Support Staff
*
Agency Principals/Officers
*
Other Agency Contacts
*
Agency Production Information
Please select all states the agency solicits business:
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Please provide largest Workers' Comp Classes of Business:
*
Please list any business segment or industry specialization(s):
*
Please list other coverages that you place:
*
Annual New & Renewal WC Production
*
Rows
New
Renewal
Service Quality
Top 3 Commercial Lines Companies & Time Represented
*
Rows
Company Name
Length of Time Represented
#1 Company
#2 Company
#3 Company
W-9, E&O, & Licenses
Please upload a copy of your W-9 (must be Oct 2018 version):
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of your E&O COI or Dec Page:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload copies of all agency licenses:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload copies of all agent licenses:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Agency Agreement
Except for lack of production, have you ever had a contract with a carrier terminated?
*
Yes
No
Please explain the carrier termination(s):
*
Have you ever had a carrier place restrictions on your agency?
*
Yes
No
Please explain the carrier restriction(s):
*
Has a license of the agency ever been revoked or suspended?
*
Yes
No
Please explain the revocation/suspension:
*
Signature
*
Name
*
Title
*
Date
*
/
Month
/
Day
Year
Date
We will also need an individual producer application completed. Please provide the email address of the individual you would like to complete it below. They will receive a link to complete the form.
*
example@example.com
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