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Brokers Agreement
NEW AGE UNDERWRITERS AGENCY, INC.
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
% of Commercial Lines
% of Personal Lines
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)
Amtrust
Associated Mutual
Attune
Blitz
BTIS
Coterie
District Cover
Foxquilt
MGT
Next
Pathpoint
Pie Insurance
Propeller
Rainbow
Root
Simply Business
Slice
Steadily
Swifft
Three
Name
Title
Your Signature
Clear
Signature Date
*
required
Click here to view & download the Brokerage Agreement
Agency License
Upload PDF File/Max 3mb.
E-Signed Brokerage Agreement
Upload PDF File/Max 3mb.
Agent License
Upload PDF File/Max 3mb.
Please attach a copy of the current Broker's License.
W9
Upload PDF File/Max 3mb.
Please attach a copy of current W-9.
E&O Expiration Date
*
required
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
Additional Documents
Upload PDF File/Max 3mb.
Comments:
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Thank you! We'll be in touch.
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