Agent/Agency Appointment Form

Agency Profile

Agency Name

Does your agency use a DBA?

Yes

No

Business Type

Corporate License

Corporate License Type

License Number (TDI)

License Expiration

Physical Address

Street Address 1

Street Address 2

City

State

Zip Code

Mailing Address same as Physical?

Mailing Address

Street Address 1

Street Address 2

City

State

Zip Code

Main Office Phone

Main Office Fax

Main Office Email

Website

Contacts

Agency Owner/Principal

First Name

Last Name

Identification Type

Social Security Number

Tax ID Number

Social Security Number

Date of Birth

Driver’s License Number

Driver’s License Expiration

Driver’s License State

Insurance License Type

License Number

License Expiration

Phone Number type

Phone Number

Email

Operations/Office Manager

Same as owner

First Name

Last Name

Date of Birth

Phone Number type

Phone Number

Email

Accounting Manager

Same as owner

First Name

Last Name

Phone Number type

Phone Number

Email

Compliance Manager

Same as owner

First Name

Last Name

Phone Number type

Phone Number

Email

Compliance

Errors and Omissions

E&O Carrier Name

Are the minimum aggregate limits $300,000 or greater?

Yes

No

E&O Expiration Date

Accounting Info

Sweep Account

Bank Name

Bank City

Bank Zip

Account Type Checking

Account Number

Routing Number

Commissions Account

Bank Name

Bank City

Bank Zip

Account Type

Checking

Savings

Account Number

Routing Number

W-9

Name as shown on income tax return

Business Name

Social Security or Employer Identification Number

SSN

EIN

Social Security Number

Additional Info

Please select your Comparative Rater

Do you have an Agency Management System

Yes

No

Top 5 Carriers

Company 1

Company 2

Company 3

Company 4

Company 5

Document Upload

TDI License

Corporate License Upload

Individual License Upload

E&O

E&O Dec Page or Binder Upload

Sweep Accounts Voided Checks Upload

Commission Accounts Voided Checks Upload

Signed W-9 Upload

Other Documents Uploads (e.g., Agency Profile)

Final Submission

If you satisfied with your answers/selections, click the Submit button to complete

Agent/Agency Appointment Form

Agency Profile

Corporate License

Physical Address

Mailing Address

Contacts

Agency Owner/Principal

Operations/Office Manager

Accounting Manager

Compliance Manager

Compliance

Errors and Omissions

Accounting Info

Sweep Account

Commissions Account

W-9

Additional Info

Top 5 Carriers

Document Upload

TDI License

E&O

Sweep Accounts Voided Checks Upload

Commission Accounts Voided Checks Upload

Signed W-9 Upload

Final Submission

Open Hours

Mon – Fri: 8:00 am to 5:00 pm
Sat - Sun: Closed