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AGENCY/BROKERAGE INFORMATION

Agency/Brokerage Name *

Business Phone *

Business Fax

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the mailing address the same as the physical address? *

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Additional Branch Locations *

Number of Locations *

Number of Employees *

Key Employees & Officers *

Website / URL

Year Established *

Business Entity Type *

Federal Tax ID/SSN *

Enter based on your Agency/Brokerage entity type. Please enter correct format.

Estimated Annual Premium *

% of Admitted Business *

Must equal 100% between Admitted & Non-Admitted Business

% of Non-Admitted Business *

Must equal 100% between Admitted & Non-Admitted Business

% of Commercial Lines Business *

Must equal 100% between Commercial & Personal Lines

% of Personal Lines Business *

Must equal 100% between Commercial & Personal Lines

% of Life & Health

Must equal 100% between Commercial, Personal Lines & Life & Health

Are you appointed with The Hartford? *

Would you like the ability to quote directly with The Hartford? *

Are you appointed with Travelers? *

OWNERSHIP INFORMATION

Agency/Brokerage Owner/s Name/s *

First

Last

Additional Owners *

Agency/Brokerage Ownership Name 2 *

First

Last

Agency/Brokerage Ownership Name 3

First

Last

LICENSING INFORMATION

Current E&O Policy *

Agency/Brokerage License

Home State Agency/Brokerage License (Company). Attach additional states licensed in same file.

Agent/Broker License *

Home State Agent/Broker License requesting appointment. Attach additional states licensed in same file.

NPN (National Producer Number)

State Drivers License/State ID *

Certify *

Yes

I understand that the information provided herein is essential and material to the agency/broker relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.

Get Appointed With Our Partner MGA

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AGENCY/BROKERAGE INFORMATION

OWNERSHIP INFORMATION

LICENSING INFORMATION

MGA Preferred Agency Network