Become an Appointed Broker

Welcome to our Broker Appointment Application

If you are interested in placing your client’s¬†insurance needs with us, please complete our Agency Interview Questionnaire.

All fields are required.

Today's Date (mm/dd/yyyy):


Year Business Established:

Web Address:

Name of Agency Interested in an Appointment:


Phone Number:

Fax Number:

Agency Principal(s):

Person completing this form and title:

How did you hear about us?

Is there any class of business in which you specialize?

In what classes of business have you been particularly competitive and had a substantial number of issues/binds in the last year?

Who are your direct Carriers?

What other Wholesaler(s) do you use?

Please provide the volume and product percentage for Commercial & Personal Lines:

What is your total 3 year loss ratio?

Describe your front-line underwriting and marketing process when submitting a risk:

What Company carries your errors & omissions coverage?


What Products and Carriers are you looking to access through us?

Enter the code that appears above into the field below: