Producer Profile

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  • Company Information

  • Primary ContactFull Physical Address 
  • Contact Information

  • TitleNamePhoneEmail 
  • Premium Information

  • Please indicate how much total premium your agency writes in each of these classes of business:

  • Coastal PropertyTransportationOther (Please Specify)
  • General LiabilityExcess / UmbrellaConstructionOther (Please Specify)
  • D&OE&OHealthcareOther (Please Specify)
  • Market Information

  • Broker / MGA NameAnnual Premium PlacedClasses Written 
  • Additional Documentation

  • Drop files here or
    1) Signed Producer Agreement
    2) W-9
    3) Copy of E&O Declaration Page
    4) Copy of Licenses
  • Date Format: MM slash DD slash YYYY
February 5th, 2016 by XS Specialty, LLC