ARE YOU READY
TO WRITE MORE BUSINESS?

Serve more clients easier, faster, and better.

Benefits to getting appointed

Generous Commissions, Online Policy Management, Brand Your Agency on Applications & Free Esign Feature!

You will need the
following documents

Legible copy of your current broker’s license

Legible copy of your broker’s bond (if applicable)

Copy of your current E&O Policy dec page

*The agency name on the producer agreement and W9 must match agency license.

"*" indicates required fields

Legal Agency Name*

DBA Name

FEIN/Tax ID*

Entity Type*

Agency Type*

Physical Address*

Street Address City State ZIP Code

Mailing Address*

Same as Physical Address

Street Address City State ZIP Code

Website

Principal Agent*

First Last

Principal Agent Phone*

Principal Agent Email*

Principal Agent License #*

Appointment Contact Information same as Principal?*

Yes

Appointment Contact*

First Last

Appointment Contact Phone*

Appointment Contact Email*

Book of Business $*

Book of Business Profile*

Hold 'ctrl' key to select more than one option.

Commercial Business %*

Personal Business %*

Health Business %*

Life Business %*

What states are you licensed to write business in?*

Hold 'ctrl' key to select more than one option.

Are you affiliated with any of the following:*

Any recent mergers or acquisitions?*

Yes

How did you hear about us?*

Does this agency have multiple locations?*

Is this agency owned by another agency that is already appointed with ISC, NNB, Paramount or Abacus?*

Is this agency the parent or child of the appointed agency?*

Do you want your own agency code?*

Appointed Agency Name*

Appointed Agency Phone*

Appointed Agency Address*

Street Address City State ZIP Code

Please list companies and MGAs you place business with in order of premium volume:

Carrier/MGA Name #1*

Annual Premium Amount #1*

12 Month Loss Ratio % #1*

Carrier/MGA Name #2*

Annual Premium Amount #2*

12 Month Loss Ratio % #2*

Carrier/MGA Name #3*

Annual Premium Amount #3*

12 Month Loss Ratio % #3*

Supplemental Information:

Have you or anyone in your agency been sued concerning insurance related activities?*

Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance?*

Has any Errors & Omissions claims been made in the most recent five years against your agency, officers, partners or owners?*

Has your agency ever been terminated by a carrier?*

If you answered yes to any of the questions above, please provide explanation here:*

Phone

This field is for validation purposes and should be left unchanged.

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Texas
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Vermont
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Wisconsin
Wyoming

ARE YOU READY TO WRITE MORE BUSINESS?

Serve more clients easier, faster, and better.

Benefits to getting appointed

You will need the following documents

Please list companies and MGAs you place business with in order of premium volume:

Supplemental Information:

ARE YOU READY
TO WRITE MORE BUSINESS?

You will need the
following documents