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Contact Information

Name*

First Last

Email*

Job Title*

Department*

Broker Information

Broker Name*

Broker Website*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone*

Fax Number*

Marketing Sales

Manager's Name*

Email*

Operations Information

How is the organization licensed? (Choose all that apply)*

Agent
Broker
Excess & Surplus Lines
Other (Please Describe Below)

Other

Please confirm that you are fully licensed in all the states in which you are submitting your business.*

Yes
No

Commission Income Breakdown*

% Retail	% Wholesale Brokerage	%MGA (Binding Authority)	% Other

Premium Volume $ (approximate for current year)*

Premium Volume selection*

% Commercial Lines	% Personal Lines	% Other (Please Describe Below)

Other

Personnel

Breakdown of Organization’s Staff (number)*

Principals/Owners	Producers (Salespeople)	Other Licensed Employees	Other Employees	Total Staff

Financial and Other Information

Internal Accounting Contact Name*

Phone*

Do you maintain Employee Dishonesty Coverage for all Officers and Employees?*

Yes
No

Do you maintain Errors & Omission Coverage?*

Yes
No

Have you or any officer, director or member of your organization ever had an insurance license suspended or terminated for any reason, or ever been subject to any disciplinary action?*

Yes (If yes, please explain)
No

Please Explain

Is there any pending or threatening litigation or judgments within the past five years exceeding $10,000 against the broker or any principals of the organization?*

Yes (If yes, please explain)
No

Please Explain

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Phone

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