Producer Profile Registration

Producer Profile Registration Form

Tell us about your company. Your information is safe with us. We will not share or sell this to any third party. Fields with asterisk (*) are required.

Date
Date Format: MM slash DD slash YYYY
Producer Firm Name*
FEIN Tax ID (Format: 00-0000000)*
National Producer Number (NIPR)*
Producer Website
Principal Information
Principal Name*
Email*
Ownership %
Add more Principal?
- Yes
Principal Name
Email
Ownership %
Principal Name
Email
Ownership %
Principal Name
Email
Ownership %
Contact Information
Physical Street Address*
Street Address Address Line 2 City State ZIP Code
Different Mailing Address?
- Yes
Mailing Address
Street Address Address Line 2 City State ZIP Code
Producer Main Phone*
Company Fax
Email – General Office
Email – Daily Billing Activity Files
Email – Policy Document Delivery
Email – Commission Statements
Email – Producer Experience Reports
Contract Contact
Contract Contact Name*
Contract Contact Phone*
Contract Contact Email*
Office Locations
Main Office Contact or Manager*
Number of Producers
Number of CSRs
Is the Physical Address also the Main Office Address*
- YES
- NO
Main Office Location
Street Address Address Line 2 City State ZIP Code
Add more office locations?
- Yes
You may also upload here an Excel (xls) sheet of all office locations
Name of Office Contact or Manager
Number of Producers
Number of CSRs
Location
Street Address Address Line 2 City State ZIP Code
Name of Office Contact or Manager
Number of Producers
Number of CSRs
Location
Street Address Address Line 2 City State ZIP Code
Name of Office Contact or Manager
Number of Producers
Number of CSRs
Location
Street Address Address Line 2 City State ZIP Code
Name of Office Contact or Manager
Number of Producers
Number of CSRs
Location
Street Address Address Line 2 City State ZIP Code
Name of Office Contact or Manager
Number of Producers
Number of CSRs
Location
Street Address Address Line 2 City State ZIP Code
Appointed States
Resident State to be Appointed*
Additional State for Appointment
Disciplinary Actions and Litigations
Has any member of your firm received any disciplinary action by a state insurance department or other regulatory authority?*
If YES, please explain
Is there any pending or threatened litigation or judgements within the past three (3) years against the agency or its employees?*
If YES, please explain
Is there any pending E&O claims within the last three (3) years?*
If YES, please explain
Do you maintain current resident licensure and non-resident licensure for all your producers?*
Total Premium Production
Commercial Premium Volume*
BOP Premium Volume*
Total Producer Volume*
List of 3 Largest Commercial Lines Carriers
Company Name
Company Name
Company Name
Terminated Companies in the last Three Years
Had your carrier cancel their appointment in the last 3 years?
- Yes
- No
Company Name
Reason for Termination
Company Name
Reason for Termination
Company Name
Reason for Termination
——————————————————————————————–
Upon agreement by both parties to proceed, the producer will be asked to submit the following documents:
- Signed Producer Agreement – (Download here)
- Copy of your Insurance Licenses issued by your state of resident
- Copy of your E&O Policy Dec Page
- For Pennsylvania Producers, PA appointments require the PA Agency license as well as all PA Individual producer license(s)
Type Your Name*

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Producer Profile Registration

Producer Profile Registration Form

Principal Information

Contact Information

Contract Contact

Office Locations

Appointed States

Disciplinary Actions and Litigations

Total Premium Production

List of 3 Largest Commercial Lines Carriers

Terminated Companies in the last Three Years