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Home > Business Commercial > MGA/Wholesaler Application
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MGA/Wholesaler Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

  • Basic Information
  • Position Responsibilities
  • Fees & Product Breakdown
First Name *
Last Name *
Name of Applicant Agency/dba if applicable *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Number of producers from whom you receive business *
Number of such producers you have appointed as agents with binding authority *
Premium Volume
Number of such producers you have appointed as agents with binding authority *
What checks and supervision do you exercise over your producers?
Do you require and verify that your producers carry E&O coverage? *

What is your minimum E&O limit requirement for sub-producers?
Does your contract with producers include a hold-harmless agreement in your favor? *

List all functions you perform as Managing General Agent or Program Administrator or agent with binding
Quoting *

Max limit of your authority
Underwriting *

Max limit of your authority
Binding *

Max limit of your authority
Policy Issurance *

Claims adjusting *

Max limit of your authority
Claims administration *

Describe
Actuarial service *

Loss Control *

Reinsurance placement *

What fees have been generated in the last 12 months from operations listed below?
Claims Adjusting *
Insurance Consulting/Advising *
Third Party Administrator *
Risk Management Consultant *
What is the approximate percentage breakdown of the total annual volume you do as?
Agent *
Broker *
Retailer *
Business direct from insureds *
Managing General Agent *
Wholesaler: *
Surplus Lines Broker *
Business accepted from other agents *
Consultant (for a fee) *
Reinsurance *
Facultative *
Treaty *
Other *
Please provide complete details of any specialty programs you manage
What minimum Best Ratings do you require as regards the companies with which you place business? *
Is all rating and policy issuance generated by an electronic system created by the companies you represent?

Do you have discretion over pricing, terms and conditions for the programs that you manage? *

If Yes, please explain
Do you have any discretion over the use of or drafting of endorsements for any of these programs? *

If Yes, please explain
How often is an audit performed by the insurers you represent? *
List and describe the circumstances behind all insurance carriers who MGA/MGU and or PA contracts have
How did you hear about us?
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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