Producer Response Request Form

Producer Response Request Form

We're pleased that you are interested in representing one of the premier insurance carriers in the United States. Just fill in the form below and one of our marketing professionals will contact you.


(* Required information)
*Agency Name
DBA:
*Contact Name
*Address
*City
*State:
*Zip
*Office Phone
Cell Phone:
Fax:
*Email
Website:
*Does your Agency have a Premium Trust Account? Yes No
*Does your Agency have an Errors & Omissions Policy? Yes No   *What are the limits? $    
*What is the deductible amount? $
*Does your Agency have Fidelity Coverage? Yes No   *What are the limits? $
*Your Agency's Annual Premium Volume:
$ Auto Rental
Type Carrier
$ Commercial Auto & Garage
Type Carrier
$ Commercial Driving Schools
Type Carrier
$ Commercial Explosives
Type Carrier
$ Commercial Property & Liability
Type Carrier
$ Limousine
Type Carrier
$ Long-Haul Trucking
Type Carrier
$ Motorcoach, School Bus & Transit Bus
Type Carrier
$ Vanpool & KidsKab
Type Carrier
Type of License: Broker      Agent    Both   Is your agency?: Wholesale  Retail
List States of License:
Do you Co-Broker any of your Accounts? Yes No
Lancer Products in which you have an interest (check all that apply):
  Auto Rental
Commercial Auto & Garage
Commercial Driving Schools
Commercial Explosives
Commercial Property & Liability
Limousine
Long-Haul Trucking
Motorcoach, School Bus & Transit Bus
Vanpool & KidsKab
Reasons for interest in Lancer as a market:
Other Lancer Product(s) Affiliation:
How did you initially hear about Lancer Insurance Company?

Comments:

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