Producer Profile
Company Information
Agency Name
*
Legal Name (If Different)
Agency ID
Website
Email Address
*
Alternate Email Address
Phone
*
Fax
*
Physical Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address (If Different Than Physical)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Accounting Address (If Different Than Physical)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Entity
*
Corporation
Partnership
Individual
LLC
If LLC, Please Select Tax Classification
C Corporation
S Corporation
Partnership
List other agency office locations that you would like added to our database. Include address and primary contact at each office. Please note that each location will be assigned it's own agency code.
Primary Contact
Full Physical Address
Contact Information
Please List Company Contacts Including Principal, Accountant, Marketing Manager, and Producers
Title
Name
Phone
Email
Do you have a small accounts department?
*
Yes
No
If Yes, Size of Accounts Sent to Department and List Department Contact
Premium Information
Agency Total Premium
*
Agency Total Commercial Premium
*
Total Placed with Wholesalers/MGAs
*
Please indicate how much total premium your agency writes in each of these classes of business:
Coastal Property
Coastal Property
Transportation
Other (Please Specify)
General Liability
General Liability
Excess / Umbrella
Construction
Other (Please Specify)
D&O
D&O
E&O
Healthcare
Other (Please Specify)
Market Information
Please list the wholesale brokers or MGAs used by your agency below:
Broker / MGA Name
Annual Premium Placed
Classes Written
Additional Documentation
Please Upload the Following Files:
Drop files here or
1) Signed Producer Agreement
2) W-9
3) Copy of E&O Declaration Page
4) Copy of Licenses
Prepared By
*
Date
*
Date Format: MM slash DD slash YYYY
February 5th, 2016
by
XS Specialty, LLC