INDEPENDENT AGENCY APPLICATION

Complete this application to request appointment as a new Independent Agency. We will ask for information about your agency practices, agency ownership, agency automation, book mix and revenue, and existing carrier information. All information will be verified. Upon approval, additional documentation will be required.

GENERAL AGENCY INFORMATION

Physical Address

Contact Information

Agency Structure

Business Information

PRINCIPAL/OWNER INFORMATION

Please ensure that the percentage of ownership adds up to 100%

Principal/Owner

REVENUE & BOOK MIX

Total Agency Volume

What percentage of business is

Please ensure that percentages add up to 100%

What percentage of auto business is

Please ensure that percentages add up to 100%

EXISTING CARRIER INFORMATION

Standard Carrier

AUTOMATION

Please type NONE if this is not applicable to your agency

SIGNATURE

By typing your name below, you certify that the information provided is accurate, to the best of your knowledge and you wish to proceed with the contracting application for your agency.