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NEW AGE UNDERWRITERS AGENCY, INC.
NEW AGE INSURANCE SERVICES, INC.
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Application
Thank you for your interest in placing business with our company. Kindly fill out the following:
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 Business
Number of Office Locations
Number of Employees
States Licensed
Agent 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?
Interested in our Aggregator Programs? (Quote, Bind and Issue Programs)
Attune
Blitz
Coterie
Foxquilt
Next
Pathpoint
Simply Business
Steadily
Victor
E&O Expiration Date
E&O Dec page or COI
Upload PDF File/Max 3mb.
Must show carrier, coverage dates, limit of liability and deductible. A minimum limit of $1,000,000
Agent License
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Please attach a copy of the current Broker's License.
Agency License
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W9
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Please attach a copy of current W-9.
Additional Documents
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Click
here
to view & download the Brokerage Agreement
E-Signed Brokerage Agreement
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Title
Your Signature
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Signature Date
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