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:*