MGA Application

Agent Details
Licensed Agent Name*
D.B.A (if applicable)
Federal Tax I.D. #*
Agency LIcenses*
Agency License # State Held
Date Agency Established*
Date of Last Change in Ownership
Is This The Home Office?*
- Yes
- No
Number of Branch Offices*
Type of Business*
- Proprietorship
- Partnership
- Corporation
- LLC
Physical Address of Office Applying*
Street Address City State ZIP Code
Mailing Address of Office Applying*
Same as previous

Street Address City State ZIP Code
Phone*
Fax*
Email*
Name of Agency Principals*
Main Contact*
Title*
Phone*
Years in Business*
Number of Licensed Producers*
Annual Gross Written Premium $*
Commercial Lines $*
Personal Lines $*
Annual Amount Financed $*
Average Policy Size $*
Current Premium Finance Company $*
Sign up for emailed notices.
Notice of Cancellation*
- E-mail
- Mail
- Both
Email
Notice of Reinstatement*
- E-mail
- Mail
- Both
Email
Disbursment Report*
- E-mail
- Mail
- Both
Email
Missing Policy # Report*
- E-mail
- Mail
- Both
Email

Agency License #	State Held

Agent Details