Become An Agent

PLEASE NOTE THAT WE ARE NOT ACCEPTING NEW AGENCY APPOINTMENTS AT THIS TIME.

Become an Agent

Become Form

Corporate Name

DBA/Agency Name

Street Address

City

State

Zip Code

Primary Contact Name

Email Address

Phone

Fax

Website

Tax ID Number

Date Agency or Location Established

Agency Book of Business Percentage(s) – Please indicate the percentage of your book of business in the following lines

Homeowners/Dwelling %

Mobile Homes %

Auto %

Commercial %

Life/Health

Other %

What is the average number of HO/DP Policies written per month?

What is the average number of Mobile Home Policies written per month?

Is there an opportunity for a rollover

Yes

If yes. from which carrier

Any additional information that you would like to provide

Agency Production - Please list your two largest personal lines carriers in order of volume

Carrier 1

Carrier 1 Name

Carrier 1 Premium

Carrier 1 Commission %

Carrier 1 Date Appointed

Carrier 1 Loss Ratio

Carrier 2

Carrier 2 Premium

Carrier 2 Name

Carrier 2 Commission %

Carrier 2 Date Appointed

Carrier 2 Loss Ratio

Become An Agent

Become an Agent

Agency Book of Business Percentage(s) – Please indicate the percentage of your book of business in the following lines

Agency Production - Please list your two largest personal lines carriers in order of volume

Carrier 1

Carrier 2

Thank you for your interest in our company(s). Our Marketing team will review this information and be in contact within 7 business days.

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Policyholders

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