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*Producer Website Producer Type*SelectRetail AgentAggregatorWholesalerFEIN Tax ID (Format: 00-0000000)*National Producer Number (NIPR)*Do you warrant that you carry surplus lines license?YesNoPrincipal InformationPrincipal Name*Email* Ownership %Add more Principal? YesPrincipal NameEmail Ownership %Principal NameEmail Ownership %Principal NameEmail Ownership %Contact InformationPhysical Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Different Mailing Address? YesMailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Producer Main Phone*Company FaxEmail – General Office Email – Daily Billing Activity Files Email – Policy Document Delivery Email – Commission Statements Email – Producer Experience Reports Contract ContactContract Contact Name*Contract Contact Phone*Contract Contact Email* Office LocationsMain Office Contact or Manager*Number of ProducersNumber of CSRsIs the Physical Address also the Main Office Address*YESNOMain Office Location Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Add more office locations? YesYou may also upload here an Excel (xls) sheet of all office locationsName of Office Contact or ManagerNumber of ProducersNumber of CSRsLocation Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Office Contact or ManagerNumber of ProducersNumber of CSRsLocation Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Office Contact or ManagerNumber of ProducersNumber of CSRsLocation Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Office Contact or ManagerNumber of ProducersNumber of CSRsLocation Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Office Contact or ManagerNumber of ProducersNumber of CSRsLocation Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Appointed StatesResident State to be Appointed*Additional State for AppointmentMinimum Insurance RequirementsErrors & Omissions (E&O) Carrier*Errors & Omissions (E&O) Limits (Minimum $1 million)*Fidelity, Crime, Employee Dishonesty*YesNoInsurance CarrierInsurance LimitDisciplinary Actions and LitigationsHas any member of your firm received any disciplinary action by a state insurance department or other regulatory authority?*SelectYESNOIf YES, please explainIs there any pending or threatened litigation or judgements within the past three (3) years against the agency or its employees?*SelectYESNOIf YES, please explainIs there any pending E&O claims within the last three (3) years?*SelectYESNOIf YES, please explainDo you maintain current resident licensure and non-resident licensure for all your producers?*SelectYESNOTotal Premium ProductionCommercial Premium Volume*$2,500,000 and below$2,500,001 to $5,000,000$5,000,001 to $15,000,000over $15,000,000BOP Premium Volume*$2,500,000 and below$2,500,001 to $5,000,000$5,000,001 to $15,000,000over $15,000,000Total Producer Volume*$2,500,000 and below$2,500,001 to $5,000,000$5,000,001 to $15,000,000over $15,000,000List of 3 Largest Commercial Lines CarriersCompany NameCompany NameCompany NameTerminated Companies in the last Three YearsHad your carrier cancel their appointment in the last 3 years?YesNoCompany NameReason for TerminationCompany NameReason for TerminationCompany NameReason for Termination——————————————————————————————–Upon agreement by both parties to proceed, the producer will be asked to submit the following documents: Sample Producer Agreement – (Download here)For Pennsylvania Producers, PA appointments require the PA Agency license as well as all PA Individual producer license(s)Type Your Name*Visit the Insurance-As-A-Service® Resources page for access at your fingertips a suite of value added resources for legal, human resource management, risk management, mental health, ergonomics and loss mitigation services.