Agent Information

Agent Appointment Application: Please have your agency license, E&O, and W-9 form available to upload.

First Name *

Last Name *

Phone *

Email *

Physical Address

Address

City

State

Postal code

Agency Information

Company Name

Corp Structure

Agent FEIN #/SSN #

Year Established

Agent Type

Agency E&O Dec Page *

Agency E&O Dec Page

Upload Agency License(s) *

Upload Agency License(s)

Agency Documents

Agency W-9 Form *

Agency W-9 Form

Banking Information

We only offer direct deposit and an email copy of your commission statements.

Banking Routing # *

Bank Account # *

Marketing Agreement

How did you hear about us?

Upload Marketing Agreement *

Who is your Insured Solutions representative?