Become an Agent

1Owner/Principal Information

Contact Information

Owner/Principal First Name *

Owner/Principal Last Name *

Email *

Owner/Principal Cell Phone

2Agency Information

Contact Information

Agency Name *

Doing Business As

Agency Phone Number *

Agency Fax Number

Agency Website URL

Batch Email

Agency Physical Address

Physical Office Street Address *

City *

ZIP *

County *

Agency Mailing Address *

Same as Physical Address?

License and Tax Status

Is the Agency Licensed with the DOI? *

Yes

Upload Agency License *

(If you do not have an agency license, upload personal license).

Choose File

No file chosen (PDF)

Agency NPN

Additional Agency Information

Year Agency Established

Number of Locations

Number of Licensed Agents

Number of Employees

3Primary Contact Information

Primary Contact/Office Manager Information

First and last name *

Primary Contact Email *

4E&O Carrier Information

E&O Exp *

E & O Dec Page Upload *

(only upload dec page of current policy)

Choose File

No file chosen (PDF)

5Top 3 Carriers for Homeowners

Carrier 1 *

Total Written Premium *

Carrier 2 *

Total Written Premium *

Carrier 3 *

Total Written Premium *

6Percentage of Agency Business

Total Personal Lines (%)

Personal Lines - Homeowners Business (%)

Other Comparative Rater

Total Commercial Lines (%)

Agency Management System

7How did you hear about us?

Additional Notes

Owner/Principal Information

Contact Information

Owner/Principal First Name *

Owner/Principal Last Name *

Email *

Owner/Principal Cell Phone

Agency Information

Contact Information

Agency Name *

Doing Business As

Agency Phone Number *

Agency Fax Number

Agency Website URL

Batch Email

Agency Physical Address

Physical Office Street Address *

City *

ZIP *

County *

Agency Mailing Address *

Same as Physical Address?

License and Tax Status

Is the Agency Licensed with the DOI? *

Yes

Upload Agency License *

(If you do not have an agency license, upload personal license).

Choose File

No file chosen (PDF)

Agency NPN

Additional Agency Information

Year Agency Established

Number of Locations

Number of Licensed Agents

Number of Employees

Primary Contact Information

Primary Contact/Office Manager Information

First and last name *

Primary Contact Email *

E&O Carrier Information

E&O Exp *

E & O Dec Page Upload *

(only upload dec page of current policy)

Choose File

No file chosen (PDF)

Top 3 Carriers for Homeowners

Carrier 1 *

Total Written Premium *

Carrier 2 *

Total Written Premium *

Carrier 3 *

Total Written Premium *

Percentage of Agency Business

Total Personal Lines (%)

Personal Lines - Homeowners Business (%)

Other Comparative Rater

Total Commercial Lines (%)

Agency Management System

How did you hear about us?

Additional Notes

What happens next

Here's what to expect when you sign up to become an agent:

1. Your application will go into a review process

2. A member of our team will contact you to discuss next steps once the review is complete

(866) 407 - 9896