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What We Cover
BOP Insurance
Worker’s Comp Insurance
Cyber Insurance
Businesses We Insure
About
Our US Management Team
News, Insights & Articles
Employment Opportunities
Support
Frequently Asked Questions
Insurance Glossary
Contact Us
Manage Policy
For Agents
Onboard Agency
Agency Portal
Agency Appointment – Step 2 – NEW
surewebadmin
2023-08-14T09:54:35+00:00
Agency Appointment
Contact Information
This field is hidden when viewing the form
Hidden AO
Hidden AP Value
Agency Name
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Person’s Full Name
(Required)
Phone
(Required)
Email
(Required)
How many BOP policies do you have in your existing book of business?
(Required)
Please enter a number greater than or equal to
0
.
Agency License Information
National Producer Number of the Agency
(Required)
State Specific License Details of the Agency
State Where Licensed
(Required)
Please Select
Ohio
Indiana
Michigan
Tennessee
Pennsylvania
License Category
(Required)
Please Select
R - Resident
N - Non-Resident
License Number
(Required)
License Expiry Date
(Required)
MM slash DD slash YYYY
License Status
(Required)
ACT - Active
INA - Inactive
Lines of Business Licensed For
(Required)
PRCS - Property & Casualty
Copy of Agency License
(Required)
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
This field is hidden when viewing the form
License Expiry Date
MM slash DD slash YYYY
+
-
State Where Licensed
Please Select
Ohio
Indiana
Michigan
Tennessee
Pennsylvania
License Category
Please Select
R - Resident
N - Non-Resident
License Number
License Expiry Date
MM slash DD slash YYYY
License Status
ACT - Active
INA - Inactive
Lines of Business Licensed For
PRCS - Property & Casualty
Copy of Agency License
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
+
-
State Where Licensed
Please Select
Ohio
Indiana
Michigan
Tennessee
Pennsylvania
License Category
Please Select
R - Resident
N - Non-Resident
License Number
License Expiry Date
MM slash DD slash YYYY
License Status
ACT - Active
INA - Inactive
Lines of Business Licensed For
PRCS - Property & Casualty
Copy of Agency License
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
+
-
State Where Licensed
Please Select
Ohio
Indiana
Michigan
Tennessee
Pennsylvania
License Category
Please Select
R - Resident
N - Non-Resident
License Number
License Expiry Date
MM slash DD slash YYYY
License Status
ACT - Active
INA - Inactive
Lines of Business Licensed For
PRCS - Property & Casualty
Copy of Agency License
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
+
-
State Where Licensed
Please Select
Ohio
Indiana
Michigan
Tennessee
Pennsylvania
License Category
Please Select
R - Resident
N - Non-Resident
License Number
License Expiry Date
MM slash DD slash YYYY
License Status
ACT - Active
INA - Inactive
Lines of Business Licensed For
PRCS - Property & Casualty
Copy of Agency License
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
Agency E&O Policy for a Limit not less than $ 1M
(Required)
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
Completed W-9 Form
(Required)
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
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