Agent Appointment Application Fields marked with* are required

Agency Name: Contact Name: Contact's E-mail address: Fax: Zip: City: Phone: Address 2: Fed Tax ID: Number of Office Locations: Number of nonstandard auto applications written last month: Total nonstandard annual written premium: Operating as: Address 1: LLC Inc. Sole Proprietor Partnership State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY Single Location 1-5 >5 <10 11-20 21-50 >50 <$250,000 $250,000-$500,000 $500,000-1,000,000 >1,000,000 * * * * * * * * * * * * * *

List your top three nonstandard auto carriers & approximate annual written premium for each one: N/S Carrier Name Approximate Annual Written Premium Are customers welcome to make payments in your office: Do you accept cash? Do you serve non-English speaking clientele? If yes, what language (50 characters) Yes No Do you have DSL, Cable or any other high-speed internet service? Yes No Yes No Yes No Your current Agent/Broker license number is: Years in business: Have you been terminated by any carrier? If yes, please explain. Have you ever been fined by the state? If yes, please explain. If we enter into a contract, my monthly new business application commitment would be: (mandatory field) Yes No Yes No Yes No Yes No Have you been given underwriting restrictions by any carrier? If yes, please explain. Has your license ever been suspended or cancelled? If yes, please explain. What Agency Management System do you use? * The official(s) signing this application certifies that all employees have been investigated and are satisfied that said employee(s) are trustworthy and meet(s) all other licensure qualifications of the applicable states General Statutes. Please note, it is the responsibility of the contracted agency to ensure that all agents are legally appointed to bind, sell, and solicit insurance on our behalf, by submitting the agent's license and personal information. * * * * * * * * * *

Please, correct the following error(s): "Agency name" field is required "Federal Tax ID" field is required "Operating as" field is required "Contact name" field is required "Contact's e-mail address" field is required "Address 1" field is required "City" field is required "State" field is required "Zip" field is required "Phone" field is required "Fax" field is required "Number of Office locations" field is required "Number of nonstandard auto applications written last month" field is required "Total nonstandard annual written premium" field is required "Application commitment" field is required "Have you ever been fined by the state" field is required "Have you been terminated by any carrier" field is required "Have you been given underwriting restrictions by any carrier" field is required "Has your license ever been suspended or cancelled" field is required "Years in Business" is required "Agent/Broker license number" field is required "Internet speed" field is required "Do you serve non-English speaking clientele" field is required "Do you accept cash" field is required "Are customers welcome to make payments in your office" field is required