Client Management Services

Home Office Physical Address (the first location is the agency Home office address.You can have unlimited Branch office within one single organization account)

Agency Ownership

Please list all of the gaency principals

First Name

M/I

Last Lame

Title

DOB (MM/DD)

Primary Telephone

Extension

Alternate Telephone

Extension

State

State Resident License

Expiration Date

% of Ownership

Has Any Principal, Partner or Officer of Your Office Ever Been Charged or Convicted of Fraud And/or a Felony? Yes No

Has Your Insurance License Ever Been Suspended And/or Revoked, or Have You Ever Been Fined by an Insurance Department? Yes No

We often work with agencies that have mutliple locations as well as multiple agents/brokers and support staff members. Based on your business operation you are able to have multiple locations and multiple users per location. Please note that agency administrator can be reassign at any time.

First Name

M/I

Last Name

Title

DOB

Primary Telephone

Extension

Alternate Telephone

Extension

State

State Resident License

Expiration Date

For an agency to be appointed, the following documents are REQUIRED

Current copy of E&O showing limits of at least 1 million aggregate. If the agency is a corporation, the E&O needs to show that the corporation is covered under the policy.
Current copy agency/agent license for the state of residence. For Florida agents, both the agent and agency license must be submitted. Please also submit any other licenses the agency may hold in any other states.
Current W-9 form – Please complete and sign. Make sure to include legal name and dba, if any. The first line of the form cannot be left blank.

Upload Documents

I hereby certify that I have reviewed this application and the information is true, correct and complete. If any information given to obtain or maintain an appointment is found to be incorrect or incomplete, it will be grounds for rejecting this application or for termination of my appointment in the sole discretion of the insurance company.

Agency Appointment

General Information

Agency Ownership

Agency Administrator

Errors and Omissions Insurance

Signature and Certification