Upload Required Documents

Upload Instructions
Click “browse” to select the file you’d like to upload and then click “upload.” Only PNG, PDF, JPEG, TIFF files are supported.
Your file has been successfully uploaded when you see “View/Remove” in each section.
You can verify that you’ve uploaded the correct document by clicking “View.”
Uploaded the wrong file? No worries, simply click “remove” and browse for a new file.

*- Required Fields
 
First Name: *
   
  Last Name: *
     
  Middle Name:
    
Upload copy of your E&O (Certificate of Liability Insurance): *
Upload W-9 Form: * Don't have a copy of the W-9 form? Download it here.
If commissions are paid to an agency, all information on W-9 must be agency information only.
If commissions are paid to an individual, all information on W-9 must be individual’s information only.
Licensed in the State of:
License # for the State: *
  
Upload copy of License: *
Background Information
If the answer is Yes to any of the below questions, you must provide additional details in the text box.
Have you ever had your insurance license suspended or revoked?
Have you ever been convicted of, or pleaded guilty or no contest to, or are charges currently pending for a felony or a misdemeanor (other than traffic violation)?
Have you ever been employed by an insurance Company, where the employment contract was terminated or non-renewed because of allegations of wrongdoing?
Have you ever been investigated or fined by an Insurance regulatory Authority?
Complete Broker Information
*- Required Fields
 
If you conduct business under a fictitious name, list here:
Position/Title:
Social Security Number: *
   Date of Birth:*
   
Resident Address
Street Address: *
 
  City: *
    
  
State: *
 
    ZIP: *
    
Business Address
Street Address: *
 
  City: *
    
  
State: *
 
    ZIP: *
    
Phone Number:*
  Fax Number:
  
Email:*
 
   Website:
   
Are you affiliated with any of these general agencies?
Do you want your comission paid to an agency?*
Complete Agency Information
If working under an Agency, please complete the following:
*- Required Fields
 
Agency's Legal Name:*
 
  Tax Identification Number:*
    
  Date of Incorporation:
  
Business Address
Street Address: *
 
  City: *
    
  
State: *
 
  ZIP: *
  
Phone Number:*
  Fax Number:
  
Email:*
 
  Website:
    
Read and Accept Broker Agreement

Review the agreement and by clicking on the checkbox, you confirm that you have read and understood the above Broker Agreement.

I have read and understood the agreement.  
Typing your name in the following box will be binding as your actual signature.  

 
Application Confirmation
Thank you for completing the requirements. Your credentials are currently being verified.
 
What’s Next?
  • Our Credentialing Department is currently verifying the validity of your documentation. The process takes about 5 to 7 business days.
  • A representative will contact you if additional documentation is needed.
  •  
    Once approved,
  • You will receive a Welcome Packet with an email confirmation, and
  • One of our Account Executives will contact you.
  •  
    If you have any questions, please call us at 1.877.760.2247