MGA/Wholesaler Application

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? *

Yes
No

What is your minimum E&O limit requirement for sub-producers?

Does your contract with producers include a hold-harmless agreement in your favor? *

Yes
No

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?

Yes
No

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

Yes
No

If Yes, please explain

Do you have any discretion over the use of or drafting of endorsements for any of these programs? *

Yes
No

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

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MGA/Wholesaler Application

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