Broker Application

For Commercial Auto & Garage and Commercial Property & Liability Divisions Only

Contact Name *
Contact Name
Phone *
Phone
Agency is
Agency is primarily: *
KEY CONTACTS AND RESPONSIBILITIES
TOP FIVE COMPANIES REPRESENTED OR GENERAL AGENCY RELATIONSHIPS
Accounting Contact
Accounting Contact
How did you hear about Lancer?
IMPORTANT

Upon form submission, please send (via email producer@lancerinsurance.com or fax 516-825-1947): - Errors & Omissions Declarations Page ($1,000,000 minimum limits required; $10,000 maximum deductible) - Broker (BR) License for each state in which you plan to write business - NY, NJ, PA & CT