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Becoming a Producer

This application is for the Urban Advantage Exclusive Program.

If you are not affiliated with Urban Advantage, click here.

Complete the online application below and we will send you an e-signature form to get started.

Have you already completed our producer agreement?
- Yes
- No
Name*
First Last
Agency Name*
Are you part of a cluster, aggregator, or other group?*
What is the name of your group, cluster, or aggregator?
What is the email address and person to whom we should send the producer agreement?
Please also tell us your group, cluster, or aggregator name.
Do you know home state insurance license number?
If you know it, please enter it here. It makes it easier for us to get you set up.
Do you know your NPN (national producer number)?
If you know it, please enter it here.
Your Business Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (optional, if different from physical address)
Email*
Enter Email Confirm Email
Office Phone*
Cell Phone*
Some companies require a cell phone number for us to set you up with access to them.
What is your role at the agency?*
About which services should someone contact you?
- Select All
- Signing up as a New Retail Agent or Agency
- BOP and GL Real Time Quoting and Binding Online
- Selling Life insurance or disability
- Selling Roadside Assistance
- Selling short-term medical, dental, or cancer insurance - send me the link to sign up
- Selling international travel medical and trip cancellation insurance - - send me the link to sign up
- Selling ID Theft
- Selling Travel (such as hotel rooms)
- Selling workers comp through referrals (you refer the client to a company, they sell it, you get commission)
- Selling payroll services
- Getting info on creating a membership club for my clients
- Lead or Client Follow Up Service
- Getting information on e-checks and credit card processing
- Premium Financing Options for My Clients
Let us know which products interest you.
Do you also have a life insurance license?
How many producers does your agency have?
Fax Number
Do you want to add additional names and email addresses for us to create logins? Please write them below.
Final Questions
Any additional comments that you want to share?

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