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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.

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

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

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

Max limit of your authority
Optional
Underwriting
Required

Max limit of your authority
Optional
Binding
Required

Max limit of your authority
Optional
Policy Issurance
Required

Claims adjusting
Required

Max limit of your authority
Optional
Claims administration
Required

Describe
Optional
Actuarial service
Required

Loss Control
Required

Reinsurance placement
Required

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

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

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

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

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