Your Agency

Owner or producer — same form. We place through licensed agents, and you keep the relationship and the commission.

About You

First Name

Last Name

Mobile

Office PhoneOptional

How should we reach you?

Your Agency

Agency Name

Are you the owner of the agency?

Agency Address

Where the agency is licensed.

Address lookup is unavailable right now — type it in and pick the state below.

Suite / UnitOptional

Agency Licence NumberOptional

WebsiteOptional

FaxOptional

A Few Questions

Has any Carrier cancelled or revoked an appointment (not production related)?

Has any officer or director pled guilty to, or been convicted of a felony involving dishonesty or breach of trust?

Has the employer entity or any owner, partner, officer or director of the employer entity, or member or manager of a limited liability company ever had an insurance agency contract or any other employer relationship with an insurance company terminated for any alleged misconduct?

Has the employer entity or any owner, partner, officer or director of the employer entity, or member or manager of a limited liability company ever been subject to a bankruptcy proceedings?

Has the employer entity or any owner, partner, officer or director of the employer entity, or member or manager of a limited liability company, ever had their insurance license revoked?

Do you assist your client with their premium audits?

If no, would you be interested in working with an audit management partner that provides revenue to your firm?

Does you Firm have a Cyber Liability Policy in Place?

Does you Firm offer stand alone Cyber Liability Insurance and Tech E&O to your Clients?

I have read and accept the Wholesale Broker Agreement and confirm I am authorised to bind this agency to it.

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