Careers
News
MENU
MENU
About
Agents
Login
Workers Compensation
Property & Casualty
Forms
Become an Agent
Policyholders
Login
Claims
Risk Management
Make a payment
Risk management
Claims
News
Become an Agent
Join us as we seek high quality, long-term partnerships
Home
Become an Agent
Agency appointment application
AGENCY INFORMATION
AGENCY NAME
Click to add
Legal entity name
(?)
Click to add
DBA
(?)
ENTITY TYPE
Corporation
LLC
Partnership
Individual
Other
PRINCIPAL OWNERS
Click to add
(?)
OWNERSHIP %
Click to add
(?)
Click to add
(?)
Click to add
(?)
Click to add
(?)
Click to add
(?)
Click to add
(?)
Click to add
(?)
TOTAL AGENCY PREMIUM
Click to add
(?)
COMMERCIAL LINES %
Click to add
(?)
Estimated total in-force premium with iSurity after 3 years
Click to add
(?)
PRIMARY LOCATION
BRANCH NAME
Click to add
(?)
PHYSICAL
Click to add
Address
(?)
Click to add
City
(?)
Click to add
State
(?)
Click to add
Zip
(?)
Click to add
Phone
(?)
Click to add
Fax
(?)
MAILING
Click to add
Address
(?)
Click to add
City
(?)
Click to add
State
(?)
Click to add
Zip
(?)
BACKGROUND INFORMATION
Has the agency, agency owners, or any agency representatives been involved in an insurance-related lawsuit? If so, explain.
Click to add
(?)
Has the agency, agency owners or any of its agents filed for bankruptcy? If so, explain.
Click to add
(?)
Has the agency, agency owners, or any agency representatives filed an E&O claim? If so, explain.
Click to add
(?)
How did you hear about iSurity?
Click to add
(?)
APPLICANT INFORMATION
NAME
Click to add
(?)
EMAIL
Click to add
(?)
PHONE
Click to add
(?)