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
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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