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Producer Application
Agency Name:*
'DBA' or Assumed Business Name:
Address 1:*
Address 2:
City:*
State:*
Zip:*
Telephone:*
Fax
Email Address:*
Agency Website:
Year Agency was established:*
Tax ID or FEIN:
Principal and percent of ownership:
Principal and percent of ownership(2):
Principal and percent of ownership(3):
Commercial Lines Manager:
Years of experience:
Personal Lines Manager:
Years of experience:
Percentage written in agency:
Commercial Lines:
Personal Lines:
Benefits:
Please list all states that your agency is licensed to write business:*
Admitted or Standard companies companies that you represent:*
General Agents / Surplus Lines Brokers you write with:*
Total Agency Volume:
Total E&S Volume:
Does your agency have a niche or specialization?
Yes
No
If yes, please comment:
How did you hear about GSU?
Document Upload:
Copy of Agency License:*
Copy of E&O declaration page:*
Home
About Us
Associations
Company Bio
GSU History
Products
Commercial P&C
Garage
Personal Lines
Transportation
Policy Services
Online Payment
Premium Financing
Report a Claim
Request Loss Runs
Contact Us
Agency Updates
Directory
Get Started with GSU
Holiday Schedule
Locations
Marketing
Privacy Notice
Request for Login
CA Consumer Privacy Act 2018 (CCPA)
Applications
Commercial P&C
Garage
Personal Lines
Transportation
News & Events
Claims
Online Payment