Producer Request Form - Baker Insurance and Bonds LLC

Have you already completed our producer agreement?

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?

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?