Agency Application
Agency Information
Agency Name
*
DBA (if applicable)
Agency Primary Email
*
example@example.com
Agency Phone
*
Please enter a valid phone number.
Agency Website
*
If your agency does not have a website, please put N/A.
Agency 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 Entity Type
*
Corporation
LLC
Partnership
Sole Proprietorship
Other
Any controlling Entity or Business Affiliation?
*
No
Yes
Controlling Entity or Business Affiliation
*
What year did the agency start?
*
Please select all states the Agency conducts 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
Contacts
Main Contact Name
*
First Name
Last Name
Main Contact Email
*
example@example.com
Main Contact Phone
*
Please enter a valid phone number.
Do you have other agency contacts you would like to provide?
*
Yes
No
Accounting/Administrator Contact Name
*
First Name
Last Name
Accounting/Administrator Contact Email
*
example@example.com
Accounting/Administrator Contact Phone
*
Please enter a valid phone number.
Agency Contacts
*
Agency Production
Would you like to provide Agency Production information so Eastern can better understand your agency and the business you write?
Yes
No
What is your Agency's Premium Volume in Commercial Lines?
$0-$1,000,000
$1,000,001-$5,000,000
$5,000,001-$10,000,000
$10,000,000+
What is your Agency's Premium Volume in Personal Lines?
$0-$1,000,000
$1,000,001-$5,000,000
$5,000,001-$10,000,000
$10,000,000+
What classes of Commercial Lines does your Agency write?
Auto Repair/Service
Contractors
Health Care
Professionals (Accountants, Lawyers, etc.)
Restaurants
Towing
Trucking
N/A
Other
What are the most important aspects in a carrier partnership?
100% Online Platform
Ability to Instant Issue Policies
Commissions
Competitive Priving
Complete Service Center Support for Customers
Ease of Doing Business
Personal Relationships
Support & Training
Other
What % of your Agency's business is commercial?
What % of your Agency's business is with Wholesalers/MGAs?
Please provide any details on agency specialization in niche markets
What is your agency's greatest product need at this time?
Top 2 Standard Markets
Market Name
Premium Volume
Standard Market 1
Standard Market 2
Top 2 E&S Markets
Market Name
Premium Volume
E&S Market 1
E&S Market 2
Premium Distribution
Commercial Premiums
Loss Ratio
Automobile
General Liability
Inland Marine
Property
Specialty Programs
Workers’ Compensation
Wholesale/E&S
W-9
Do you have a completed W-9 (Oct. 2018 version)?
*
Yes
No
FEIN
*
Please complete and download the W-9 Oct. 2018 version below:
Oct. 2018 W-9
Please upload your completed W-9 (Oct. 2018 version) 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 below:
*
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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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of
Does your agency have any Surplus Lines licenses?
*
Yes
No
Please upload all Surplus Lines licenses below:
*
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Electronic Funds Transfer (EFT)
Account Holder
*
Account Type:
*
Checking
Savings
Money Market
Other
Financial Institution Name
*
Financial Institution Phone
*
Please enter a valid phone number.
Financial Institution 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
Account Number
*
Bank Transit/ABA Number
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please upload a copy of a voided check below:
*
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Agency Agreement
Please review the Agency Agreement below:
Have you been convicted of any felonies in the last 5 years?
*
Yes
No
Please provide details on the felony(ies):
*
Have you or your agency had any disciplinary action from the Department of Insurance?
*
Yes
No
Please provide details on the DOI action:
*
Sub-Producer
*
SIGNATURE
*
Printed Name
*
Date
*
/
Month
/
Day
Year
Date
Nexsure Portal Login
Yes
SUBPRODUCER ID NUMBER EUM
Submit to Eastern Underwriting Managers
Submit to Eastern Underwriting Managers
Should be Empty: