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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
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)
Amtrust
Attune
Blitz
Coterie
Foxquilt
Next
Pathpoint
Propeller
Rainbow
Root
Simply Business
Steadily
Swifft
Three
Victor
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
Agent License
Upload PDF File/Max 3mb.
Please attach a copy of the current Broker's License.
Agency License
Upload PDF File/Max 3mb.
W9
Upload PDF File/Max 3mb.
Please attach a copy of current W-9.
Additional Documents
Upload PDF File/Max 3mb.
Click here to view & download the Brokerage Agreement
E-Signed Brokerage Agreement
Upload PDF File/Max 3mb.
Name
Title
Your Signature
Clear
Signature Date
*
required
Comments:
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Thank you! We'll be in touch.
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