Get Appointed

Name of Person having ownership in agency*
Email Address
All Employees (INCLUDING OWNER)*
Employee Name Title Email Address Admin Rights Y/N
Have you or anyone in your agency been sued concerning insurance related activities?*
- Yes
- No
Please explain
Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance?*
- Yes
- No
Please explain
Has any Error & Omission claims been made in the most recent five years against your agency, officers, partners or owners?*
- Yes
- No
Please explain
Please list companies and MGAs you place business with in order of premium volume:*
Carrier/MGA Loss Ratio

1.) Legible copy of your current broker’s license*
Accepted file types: pdf, jpg, docx, png, Max. file size: 64 MB.
2.) Legible copy of your broker’s bond (if applicable)
Accepted file types: pdf, jpg, docx, png, Max. file size: 64 MB.
3.) Copy of your current E & O Policy declaration page*
Accepted file types: pdf, jpg, docx, png, Max. file size: 64 MB.
4.) Completed W-9 Form*
Accepted file types: pdf, jpg, docx, png, Max. file size: 64 MB.
Name: Principal Name*

By adding my name, and submitting this application I am agreeing that that the statements on this application or any material submitted herewith are true and accurate representation of the applicant and they shall be deemed material to the acceptance of risk(s) from the brokerage by SIS Wholesale Insurance Services.
Signature Date
MM slash DD slash YYYY
Signature

Get Appointed with ISC

Employee Name	Title	Email Address	Admin Rights Y/N

Carrier/MGA	Loss Ratio