Get Appointed

Step 1 of 3

  1. First Name(*)
    Please type your full name.
  2. Last Name(*)
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  3. Agency Name
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  4. Street
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  5. City
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  6. State
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  7. Zip
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  8. Phone(*)
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  9. E-mail(*)
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  10. URL
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  11.  
  1. Lead Source
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  2. License States
    Please tell us how big is your company.
  3. Year Established
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  4. Principal's Name
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  5. Total Number of Producers
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  6. A/S/P ever declared bankruptcy?
  7. A/S/P ever been convicted of a felony?
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  8. A/S/P ever been refused a license?
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  9. A/S/P ever been investigated by DOI?
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  10. Agency acts as whslr/appts subprod srcs?
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  11.  
  1. Total Workers Compensation Volume
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  2. Total Property: Casualty Volume (Excluding Workers Compensation)
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  3. Direct Appointment
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  4. WC States
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  5. Amount of E&O Coverage
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  6. E&O Claims in the past 5 years
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  7. E&O discipline/investigated by DOI
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  8. E&O Expiration Date
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  9.