Get Appointed

You will need the following documents

Legible copy of your current broker's license

Legible copy of your broker’s bond (if applicable)

Copy of your current E&O Policy dec page

*The agency name on the producer agreement and W9 must match agency license.

"*" indicates required fields

Legal Agency Name*

DBA Name

FEIN/Tax ID*

Domicile State - Currently, we have products available in the following states: Texas, Arizona, New Mexico, California.*

Website

Entity Type*

Agency Type*

Physical Address*

Street Address City State ZIP Code

Mailing Address*

Same as Physical Address

Street Address City State ZIP Code

Principal Agent*

First Last

Principal Agent Phone*

Principal Agent Email*

Principal Agent License #*

Appointment Contact Information same as Principal?*

Yes

Appointment Contact*

First Last

Appointment Contact Phone*

Appointment Contact Email*

Transportation Book of Business $*

Book of Business $*

Book of Business Profile*

Hold 'ctrl' key to select more than one option.

Commercial Business %*

Personal Business %*

What states are you licensed to write business in?*

Hold 'ctrl' key to select more than one option.

Are you affiliated with any of the following:*

Any recent mergers or acquisitions?*

Yes

Please list companies and MGAs you place business with in order of premium volume:

Carrier/MGA Name #1*

Annual Premium Amount #1*

Loss Ratio % #1*

Carrier/MGA Name #2*

Annual Premium Amount #2*

Loss Ratio % #2*

Carrier/MGA Name #3*

Annual Premium Amount #3

Loss Ratio % #3

Supplemental Information

Have you or anyone in your agency been sued concerning insurance related activities?*

Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance?*

Has any Errors & Omissions claims been made in the most recent five years against your agency, officers, partners or owners?*

Has your agency ever been terminated by a carrier?*

If you answered yes to any of the questions above, please provide explanation here:*

Can you commit to writing $100,000 in PD & Cargo in the next 12 months?*

How did you hear about us?*

Name

This field is for validation purposes and should be left unchanged.

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

Get Appointed

You will need the following documents

Please list companies and MGAs you place business with in order of premium volume:

Supplemental Information

Business Hours