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Rating
Login ID
Password
Forgot Login Info?
GET RATER ACCESS NOW:
Our two step process to submit a request to join as our producer;
Please complete the online information below; then
Upload the completed and signed documents listed below.
UPLOAD AND GET ACCESS NOW
PRIOR TO BINDING BUSINESS:
Completed and signed W-9 (Click
here
)
Completed and signed Producer Agreement (Click
here
)
Copy of your resident insurance license.
Copy of your current E & O declaration page.
GENERAL INFORMATION
MGA
MGA Prefix
AGENCY NAME
DBA - C/O
International address
Yes
No
STREET
CITY
STATE
ZIP
zip will fill in City and State
PASSWORD
Please change your password
ACCOUNT TYPE
ADMINISTRATIVE
CONTACT
EMAIL
PHONE
CELL
FAX
MAILING
ADDRESS
same as above
STREET
CITY
STATE
ZIP
ACCOUNTING
CONTACT
ADDRESS
same as mailing
STREET
CITY
STATE
ZIP
EMAIL
EMAILCC
PHONE
CELL
FAX
WEB SITE
ORGANIZATION
Unspecified
Individual
Partnership
Joint Venture
Corporation
Subchapter S Corporation
Not for Profit Org
LLC
Trust
Municipality
Other
Describe
Number of Members
AGENCY TIN - Tax Payer Identification number
EXTERNAL BROKER ID
TOTAL ANNUAL PREMIUM VOLUME OF AGENCY
DATE AGENCY STARTED
NUMBER OF STAFF
SPECIALTY (IF ANY) OF AGENCY
PERCENTAGE OF PREMIUM VOLUME
Errors and Omissions
Date E&O Expires
Fidelity Insurance
Date Fidelity Expires
HAS YOUR AGENCY LICENSE EVER BEEN SUSPENDED OR REVOKED?
Yes
No
PLEASE EXPLAIN
Directions
Comments
Item
License Info
Type
Select Type
P & C
Surplus Lines
State
Number
Effective Date
Expiration Date
LIST OWNERS, PARTNERS OR CORPORATE OFFICERS:
Name
Title
EMail
Phone
UPLOAD THE FOLLOWING DOCUMENTS: