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Legal Agency Name

DBA

Street Address

Street Address Line 2

City

State

Postal / Zip code

Primary Email

Secondary Email (commercial/personal agent, employees) N/A - if not applicable

Website

Phone

EXT#

Years in Business

Total Agency Volume

Percentage

# of Location

# of Employees

States Licensed

Agent NPN # (https://nipr.com/help/look‐up‐your‐npn)

Agency NPN # (https://nipr.com/help/look‐up‐your‐npn)

Niche Target/Market's?

Top 5 Direct Carriers

Affiliated with any other Aggregator or Cluster group?

E&O Expiration Date

E&O Declaration Page

Upload File

Broker/State License

Upload File

W-9

Upload File

I agree to the terms & conditionsView terms of use

Agent Name

Your Signature

Signature Date

Comments:

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