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Click here Agency / Agent StatusNot ActiveActiveRejectedRejection Reason(Required) Agent ID SECTION 1 ~ GENERAL INFORMATIONAgency Name:(Required) First Name Last Name Agency Principal: Title: Agency Street Address:(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Location Type: Store Front Office Park Stand Alone Other Agency Mailing Address Mailing Address is different Agency Mailing Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Agency Telephone #:(Required)Agency Fax #: Website(Required) Agency General Email:(Required) SECTION 2 ~ AGENCY INFORMATIONLexis Nexis / Choice Point Node ID: *If you do not have Node ID, you will need to complete online application with Lexis NexisDate Agent Founded: MM slash DD slash YYYY **If less than 2 years, provide business planNumber of Offices:Does each office require its own sub-code? Yes No Branch Location Address(es) (other than main location listed above): Add RemoveOwnership interest in other insurance agencies or companies? Yes No If yes, please describe: Is P&C the primary business of the agency? Yes No If No, please comment: E&O Coverage Yes No Note: A minimum of $1,000,000 of E&O coverage is required.Carrier Limits Current Rating Software Used: Number of CSRs: Number of Producers: Total Agency Volume: Personal Auto: Personal OTA: Commercial Auto: Commercial OTA: Life Insurance: Home Insurance: P&C and Life MarketsYear Total AppointedCompanyLife VolumePL VolumeCL VolumeTotal Company Volume Add RemoveTotals CL Auto LSC Carrier (MA only): Please provide any feedback on loss activity that has impacted the performance of the books noted above. Explain any year end loss ratios over 65%. (Not applicable for Life)Average Growth over the past year: Average Number of Apps. Written (previous year):PL /Month:CL /Month:Life/Month:What volume can we expect?Personal $Commercial $Home $Primary Company Used for:Primary Company Used for:Personal Non-Standard Auto: Personal Standard Auto: Personal OTA: Commercial Auto: Commercial OTA: Life Insurance: Describe the primary territories/counties the agency targets for business: Current Advertising Methods (Check all that apply): Yellow Pages Direct Mail TV/Radio Internet Referrals Other Other Reason Foreign Languages Spoken in Agency: Spanish Chinese Japanese Filipino Korean Vietnamese Other Other Reason Does the agency maintain a Business Development Plan? Yes No Business Development PlanMax. file size: 512 MB.Describe any specialty programs or affinity programs offered by the agency:Percentage of New Business based on the following activities:AcquisitionsAdvertisingAdvertisingWalk InsInternetOtherDoes the agency accept brokered business from other agencies? Yes No If yes, from who and what type of business? Does the agency broker business through other agencies? Yes No If yes, with who and what type of business? Does the agency utilize premium finance companies? Yes No If yes, what lines of business? Life Section:How many licensed CSRs/Producers sell Life Insurance for your agency? Do you have direct Life appointments or go through a brokerage firm? Direct Brokerage Both What Life products do you sell the most of? TL WL Annuity Other SECTION 3 ~ BACKGROUND INFORMATIONHas your agency or any of the Principals or owners of the agency been subject to a fine or disciplinary action from the department of insurance or any other regulatory agency? Yes No Please Explain(Required) Have you ever had an insurance license denied, revoked, or suspended by any state? Yes No Please Explain(Required) Has the agency been terminated by another company in the past 3 years? Yes No Please Explain(Required) Are you now the subject of any complaint, investigation, or proceeding which could result in a yes answer to any of the above questions? Yes No Please Explain(Required) SECTION 4 ~ AGENCY KEY CONTACTS INFORMATIONPrincipal:Principal:Name Telephone Fax Email Mgr (PL):Mgr (PL):Name Telephone Fax Email Mgr (CL):Mgr (CL):Name TelephoneFax Email Licensing:Licensing:Name TelephoneFax Email Accounting:Accounting:Name TelephoneFax Email SystemsSystemsName TelephoneFax Email Key Staff Members(Required)NamePositionPhoneEmail Add RemoveSECTION 5 ~ APPLICANT ACKNOWLEDGEMENT/CONSENTI hereby certify that I have read and understand the items on this form and that my answers are true and complete to the best of my knowledge. I understand that if any of the information I provided is found to be incorrect or incomplete, it may be grounds for non-appointment or my immediate termination at the discretion of the Company.I understand that a routine inquiry may be made as a requirement for state appointment. If applicable, the Company may obtain reports from a consumer reporting agency, an investigation report or inquiries from a State Insurance Department. Any information that the Company obtains about me will be treated as confidential.FAIR CREDIT REPORTING ACT – As part of its regular procedures, the Company may obtain an investigative consumer report. It may deal with character, reputation, personal traits and lifestyle. It may involve personal interviews with friends, neighbors and associates.I understand I have the right to make, within a reasonable amount of time, a written request for details on the name and address of the agency making the report. I further understand that, depending on the state law, subjects of an investigative consumer report may have the right to: 1) request that they be interviewed in connection with the making of the report; and 2) receive a copy of the report, upon request.In signing this application I certify that I have not been convicted of any criminal felony involving dishonesty or breach of trust or been convicted of an offense under section 1033 of the Violent Crime and Law Enforcement Act of 1994. I further agree to immediately inform the Company of any conviction of the types described in the preceding sentence. I have read the above statements. My signature below constitutes my agreement and authorization to all of the above.Applicant’s Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Applicant’s Name Title
