Get Appointed

YOUR WHOLESALE INSURANCE SOLUTION

- Step 1 of 6

CONTINUED…

Personal Email *

Personal Email Address

Cell Phone

Cell Phone Number

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AGENCY/BROKERAGE INFORMATION

Agency/Brokerage Name (confirm)

Address Line 1 *

Address Line 2

City *

State Code *

Zip Code *

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

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Business Entity Type *

% of Commercial Lines Business *

Does your Agency/Brokerage use Salesforce? *

Are you appointed with The Hartford for Commercial Lines? *

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

Are you appointed with Travelers for Commercial Lines? *

Would you like the ability to quote directly with Travelers? *

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Do you have a current E&O Policy? *

Expiration Date

MM/DD/YYYY

Would you like an E&O quote now or at renewal? *

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OWNERSHIP INFORMATION

Agency/Brokerage Ownership Name/s *

LICENSING INFORMATION

State/s Licensed In

Current E&O Policy *

W9 Form

Please complete W9 and upload.

Upload W9 Form *

Agent/Broker License/s (P&C/Life/Health) *

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

Agency/ Brokerage License/s

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

State Drivers License *

Agent/Broker requesting appointment.

Agent/Broker NPN (National Producer Number)

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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.

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