United States Broker Appointment Application


*  Mandatory

 I certify that the information I provided in this online application is accurate and complete based upon my knowledge and belief at the time it was entered. *    

General Information


1. Name of Company *
2. Street Address *
3. City *
4. State/Province *    
5. Zip Code *
6. Country *    
7. Contact First Name *
8. Contact Last Name *
9. Contact Phone *
10. Contact Email *
11. Business Type    
12. Tax Id #
13. DUNS #
14. Year Established (YYYY) *

Financial Information


15. Do you have Errors & Omissions Insurance in-force? *    
16. Do you have Fidelity Insurance in-force? *    
17. What is your TOTAL(new/renewal business) annual total company revenue (excluding acquisitions)?    
    17.1. Projected next year *
    17.2. Current Year *
    17.3. Prior Year *
18. What is your TOTAL(new/renewal business) annual total company Gross Premium Written?    
    18.1. Projected Next Year *
    18.2. Current Year *
    18.3. Prior Year *
19. What is your NEW annual total company revenue (excluding acquisitions)?    
    19.1. Projected Next Year *
    19.2. Current Year *
    19.3. Prior Year *
20. What is your NEW annual total company Gross Premium Written?    
    20.1. Projected next year *
    20.2. Current year *
    20.3. Prior Year *

Current Book of Business Information


21. Does your firm specialize in commercial insurance products? *    
22. Does your firm specialize in consumer insurance products? *    
23. Personal Lines (Non Life)
24. Accident and Health
25. Benefits

Additional Information


26. Please let us know about anything else we should take into account for this appointment application.    
27. Please list any Memberships & Associations that you are a part of    

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