New Producer Agreement

Complete this once and electronically sign to finish your appointment. Your signature applies to the Producer Agreement, Personal Guaranty, Information Form, Commission Schedule, and IRS W-9 — all at once. You’ll receive a signed copy by email.

Agency / Business

Agency / Business Legal Name *

DBA (if any)

Entity Type *

Federal Employer ID Number (EIN)

Business EIN only — do not enter a Social Security Number.

Date Business Established

Number of Employees

Website

Owner / Primary Contact

Full Name (owner / principal) *

Title / Role *

Direct Phone *

Fax

Email *

Agency Location Address

Street Address *

City *

State *

ZIP *

Mailing address is the same as location

Licensing

National Producer Number (NPN) *

Primary State of Licensure *

License Number *

License Expiration *

Additional Licensed State(s)

Additional License Number(s)

Errors & Omissions (E&O)

E&O Carrier

Policy Number

Expiration Date

Per-Claim Limit

Aggregate Limit

Book of Business

Lines of Business Written

Niche / Target Industries

Estimated Annual Premium (whole agency)

Additional Users to Appoint (optional)

Sign the agreement

Your signature applies to the Producer Agreement, Personal Guaranty, Information Form, Commission Schedule, and W-9 as one electronically signed package.

Draw your signature here

Type your full legal name *

By typing my name and checking this box, I adopt this as my electronic signature and affirm that it is the legal equivalent of my handwritten signature under the federal ESIGN Act (15 U.S.C. §7001) and applicable state UETA. I certify that the statements in this document are true and accurate to the best of my knowledge.