Get Appointed: New Agent Setup – SCRIPT TESTGet AppointedInstructions & RequirementsPlease allow 15-20 minutes to complete the application. Enter agency information Sign the Producer Agreement Receive a welcome email with login credentials once your information is verified. Note: There are two signatures required to complete this set up, 1) Verification that the Agent Set Up Information is accurate, and 2) Producer Agreement Signature which must be the Principal Agent. In most cases this will be the same person.You will need the following documents: Copy of Agency License Copy of Producer License Copy of E&O Dec Page W-9 Form If you would like to view the producer agreement form you can download it here.NextStep 1: Agency Information“*” indicates required fieldsLegal Agency Name * DBA Name Entity type * —Please choose an option—CorporationLLCPartnershipS-CorporationSole ProprietorshipTrust/EstateEIN Agency type * —Please choose an option—Retail AgencyMGA/WholesalerNational Producer Number (Agency) Physical address * Street addressCity—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZipState Domiciled —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMailing address * Same as Physical address Street addressCity—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZipBilling address Street addressCity—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZipWebsite Email Domain (Ex: bigagency.com) Would you like to receive a 1099?YesNoBank Name Bank Contact Bank Phone Routing Number Account Number BackNextStep 2: Principal & Appointment ContactPrincipal agent *Legal First NameLegal Last NameTitlePrincipal agent phone * Principal agent email * Principal agent license # * Principal agent NPN # * Appointment Contact Information same as Principal? *YesNoAppointment contact *Legal First NameLegal Last NameTitleAppointment contact phone * Appointment contact email * Designated Non-Resident Producer licensed for all states. List up to two agents. Agent #1Legal First NameLegal Last NameTitleEmail NPN # List of Non-Resident States —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHold 'ctrl' key to select more than one option.Agent #2Legal First NameLegal Last NameTitleEmail NPN # List of Non-Resident States —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHold 'ctrl' key to select more than one option.BackNextStep 3: Agency OperationsPortal Administrator *Legal First NameLegal Last NameTitlePortal Administrator Email Agency Commission Statement Email * Agency EFT Notice Email * Agency Banking Email Agency Policy Print Email * Agency Policy Print Email (2) Book of business $ * —Please choose an option—Under $5M$5M – Less than $15M$15M+Book of business profile * AgricultureAutomotiveConstructionFinanceHealthcareHospitalityManufacturingMarineNon-ProfitPropertyProperty ManagementRestaurantsRetail/Wholesale StoresTransportationHold 'ctrl' key to select more than one option.Commercial business % * Personal business % * Health business % * Life business % * Are you affiliated with any of the following: * UnaffiliatedAlkemeBrightway InsuranceCombined Agents of AmericaFirstChoiceFirstConnectIndium:Insurance Assocites of AmericaInsurors GroupISU SteadfastKeystone Insurers Group Inc.PacWest AlliancePIIBRenaissanceSBMP Insurance GroupSecureRiskSIAAThe Agency CollectiveThe Iroquois GroupUnited AgenciesAny recent mergers or acquisitions? * —Please choose an option—YesNoPlease give details: How did you hear about us? * —Please choose an option—Big IContacted by RepresentativeInternet SearchEmailLinkedInProgramBusiness.comReferralTrade ShowMy New MarketsInsurance JournalOther Berkley OUDoes this agency have multiple locations? * —Please choose an option—YesNoBackNextStep 4: Carrier/MGA RelationshipsPlease list companies and MGAs you place business with in order of premium volume:Carrier/MGA Name #1 * Annual Premium Amount #1 * 12 Month Loss Ratio % #1 * Carrier/MGA Name #2 * Annual Premium Amount #2 * 12 Month Loss Ratio % #2 * Carrier/MGA Name #3 * Annual Premium Amount #3 * 12 Month Loss Ratio % #3 * BackNextStep 5: Compliance QuestionsSupplemental InformationHave you or anyone in your agency been sued concerning insurance related activities? * —Please choose an option—YesNoDescribe suit: Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance? * —Please choose an option—YesNoDescription of discipline: Have any Errors & Omissions claims been made in the most recent five years against your agency, officers, partners or owners? * —Please choose an option—YesNoDescribe errors & omissions claims: Has your agency ever been terminated by a carrier? * —Please choose an option—YesNoDescribe carrier termination: BackNextStep 6: Upload Required DocumentsRequired Agency DocumentationMaximum upload size is 10 MB per file. If you are unable to upload due to file size, please send attachments to [email protected]File upload #1 Agency License File upload #2 E&O Dec Page File upload #3 W-9 Form File upload #4 Banking for EFT File upload #5 Producer License BackNextStep 7: Review & Sign Producer AgreementSignaturesI affirm that all information is true and accurate to the best of my knowledgeI verify that the Agent Set Up Information is true and accurate. * Signature of Principal Agent * By typing my name in the field below, I authorize that I am the Principal Agent. I acknowledge that my electronic signature is legally binding and equivalent to my handwritten signature.Please leave this field empty. Back
