GET STARTED Type of Insurance Entity * Select Retail Agent Wholesale/MGA/MGU/Program Administrator RATING STATE Rating State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Policy Form Type Agency/Brokerage E&O MGA PREFERRED AGENCY NETWORK INFORMATION Are you a MGA Preferred Agency Network Member? * Select No Yes Would you like more information on MGA Preferred Agency Network? * Select No Yes AGENCY/BROKERAGE LOCATION INFORMATION State Code * Select AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
What is the legal structure of the Agency/Brokerage? * Select Individual/Sole Proprietor Partnership Corporation Joint Venture Subchaapter S (S-Corp) Not For Profit LLC Other
Does the Agency/Brokerage have a website? * Select Yes No
Does the Agency/Brokerage have multiple locations? * Select Yes No
AGENCY/BROKERAGE CONTACT INFORMATION COVERAGE FOR YOUR AGENCY/BROKERAGE Liability limits * Select 1 mill/1mill 1 mill/2 mill 2 mill/2 mill 2 mill/4 mill 5 mill/ 5 mill
Deductible * Select $2,500 $5,000 $7,500 $10,000
Property deductible. * Select 500 1,000 2,500 5,000 10,000 25,000 CERTIFY INFORMATION Certify *
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.