Broker Apllication

Commercial Auto & Garage
Commercial Property & Liability
Broker Application

 

Please provide the following information:


(* Required information)
*Agency Name:
DBA:
*Contact Name:
*Address:
*City:
*State:
   *Zip:
*Mailing Address:
*City:
*State:
   *Zip: 
*Phone:
Fax:
*Email:
Federal Tax ID:
Policy Distribution Email:

Agency is:    Corporation Individual Partnership Other (specify):

Agency is primarily:    Retail Wholesale Combination

 
Key Contacts and Responsibilities:
Name Title/Responsibilities

Top Five Companies Represented or General Agency Relationships
Company Name
or General Agent
Year
Appointed
Commercial Lines
Annual Written Premium
Average 3 Year
Loss Ratio
$ %
$ %
$ %
$ %
$ %

    Premium Trust Account Bank Information

Bank Name:
Bank Address:
Bank City:
Bank State:
Bank Zip:
Accounting Contact:
Accounting Email:
How did you hear about Lancer? (check one)
Trade Show Direct Mail Print Ad Website Word of Mouth
Visit from Marketing Rep - Name: Other
:

*Does your Agency have an Errors & Omissions Policy? Yes No
*What are the limits? $     *What's the deductible amount? $
For an E&O policy application, you may contact the Professional Agents Association at www.piaonline.org.

Type of License: Broker   Agent   Both   New York licensees - Read IMPORTANT notice below.
List States of License:     License Number:

IMPORTANT:
You must hold a resident or non-resident New York Brokers license to place/obtain insurance through our company. Broker license numbers have a "BR" prefix. New York Agents' licenses have a "PC" prefix. Agent licenses cannot be used to place/obtain coverage through insurers which operate on a admitted basis unless the firm is specifically licensed by the insurer as an agent (including placement made through wholesalers) and/or insurers which operate on an excess and surplus lines basis. If you do not have a BR license, you can obtain one quickly by visiting the New York State Department of Financial Services' website at
www.dfs.ny.gov/insurance/licinfo.htm#pc.

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