Platinum Broker Appointment

Agency Name *

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Address

Street Address Address Line 2 City State/Region/Province Postal / Zip Code Country
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Agency Website

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Agency Management System

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Agency Main Contact Information
First Name *

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Last Name *

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Title

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Email Address

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Agency Volume and Location
Number of Agency Location *

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Number of WC Producers *

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Total Worker's Compensation Premium($) *

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How much Worker's Comp premium was written last year? *

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Years in Business *

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Does your agency place business with PEOs?

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Opportunities
What are your top 5 commercial Carriers with direct appointments (by premium size) *

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What is your industry focus (e.g general or niche classes) If niche classes, please list them below *

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Is your agency willing to commit to a minimum volume of written premium? if so what sort of annual volume would you consider reasonably achievable? *

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Submission of this form does not guarantee an appointment.