Agent Appointment Application
Agency Name
*
FEIN Number
*
NPN Number
*
Agency Service Email
*
example@example.com
Agency Phone
*
-
Area Code
Phone Number
Home State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Agency Contact Name and Title
*
Agency Contact Email
*
example@example.com
Agency Contact NPN Number
*
Agency Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Producers Phone Number
*
-
Area Code
Phone Number
Producer's Email Address
ex: wbrady@myfavoriteagency.com
Agency Management Info
Which Agency Management System do you use?
*
AMS360
EPIC
Ezlynx
Hawksoft
No Agency Management System
Which Rater do you use?
*
EZLynx
PL Rater
ITC Turborater
No Rater
Total Personal Lines Volume
*
Additional Documents:
Attach a copy of E&O:
*
Browse Files
Cancel
of
W-9
*
Browse Files
Cancel
of
Primary Contact:
Name: Phone: Email Address:
Accounting/Commissions Contact:
Name: Phone: Email Address:
Licensing Contact:
Name: Phone: Email Address:
SUBMIT
Should be Empty: