1Agency profile2Trucking insurance profile3Agency experience4Additional information5Sign agreement6Producer agreement EmailThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formChannel managerThis field is hidden when viewing the formPlease select manager that invited you to this form*Richard Sturm1. About your AgencyProducer is*CorporationLLCPartnershipIndividualSSN*Based on the USA Patriot Act of 2001, we are required to identify all persons using our services. The Social Security Number must match the agency's name.FEIN (Tax ID)*Based on the USA Patriot Act of 2001, we are required to identify all entities using our services. The FEIN/Tax ID Number must match the agency's name.National Producer Number (NPN)*The National Producer Number is a unique NAIC identifier assigned through the licensing application process or the NAIC reporting systems to individuals and business entities (including, but not limited to producers, adjusters, and navigators) engaged in insurance related activities regulated by a state insurance department. The NPN is used to track those individuals and business entities on a national basis.to find your National Producer Number (NPN), click here https://www.nipr.com/PacNpnSearch.htmAgency name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Principal Name* First Last Title*Principal Email* Use Principal email to CC quotes Email quotes should be CC* Date Agency Established* MM slash DD slash YYYY Mailing address is different than physical address WebsiteMailing address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Fax*Email address(es)*Contact TypeContact NameEmailPhoneInsurance experienceHas insurance license Please provide contact info for Quotes, Binding, Accounting, Certificates, other. Please list your producers’ names and years experience here as well.What types P&C risks you write?*TruckingPersonal LinesBOPArtisan ContractorsNon-profitsMonoline PropertyMain Street BusinessesOtherMulti select with CTRL+Mouse1 Trucking business risks informationPrimary trucking written premiums per year*Primary LiabilityCargoPhysical DamageOther risks written premiums per year*Non-trucking LiabilityOccupational AccidentWorker’s CompTotal Trucking Premiums written*Current yearLast yearPrior yearOther (specify)Types of loads you are writing*General FreightHousehold GoodsBuilding MaterialsFresh ProducePassengersLivestockRefrigerated FoodChemicalsHAZMATMulti select with CTRL+Mouse1Radius of of written risks*Up to 300 MilesUp to 700 milesUnimitedPlease indicate current pricing range by line.Primary Liability* We don't write Primary Liability risk Cargo* We don't write Cargo risk Physical Damage* We don't write Physical Damage risk Non-trucking liability* We don't write Non-trucking Liability risk OtherRiskPrice level What direct truck markets do you currently use?*Company nameCoverageYears Used What MGA's do you use for Trucking Risks?*Company nameCoverageYears Used Does your agency need another truck market? If yes, why? Total Production informationTotal Premiums written*Current yearLast yearPrior yearPremiums by risks written (other than trucking)*RiskPremiums per year 3 main Carriers by Premiums written*CarrierLast yearPrior year Does your agency need other markets? If yes, what and why? What states are you licensed?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificMulti select with CTRL+Mouse1What states do you have offices?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAdditional information about AgencyThis information will help us better to understand your business approach and if our partnership can be beneficial.How do you market your services?What products or services could you use that you don’t currently have?Assuming AGENTSHOUSE can provide quality products at competitive prices, how much business could we write for your agency?Please tell us anything else about your agency that might be important, interesting, or unique: Signature requiredSignature and initials created here will be used in next step to sign contract and documents to bind coverage.Method* use your name as signature sign online with e-Signature Name First Last SignatureGenerated signature from name* Please sign* Click here to sign Reset InitialsGenerated signature initials from name* Please create your initials* Click here to sign Reset Document upload*Please upload your: • W9 Tax Form W9 form to download • Copy of Current E&O Declarations Page • Copy of Current Producer and Agency License(s) Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, ppt, pptx, pps, jpg, png, gif, Max. file size: 8 MB, Max. files: 10. • W9 Tax Form W9 form to download • Copy of Current E&O Declarations Page • Copy of Current Producer and Agency License(s) I will send these documents to Agentshouse by e-mail or fax. Producer AgreementThis Producer Agreement will be executed as of the Date of first binding request by the Producer. PDF Preview Agreement confirmation* I have read and understand this agreement, and accept and agree to all of its terms and conditions. I want to cancel submission, all information will be lost
