Portland Become a Producer Form

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 State ZIP Code
Mailing Address (If Different Than Physical)
Street Address Address Line 2 City State ZIP Code
Accounting Address (If Different Than Physical)
Street Address Address Line 2 City 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*

Primary Contact	Full Physical Address

Title	Name	Phone	Email

Broker / MGA Name	Annual Premium Placed	Classes Written

Producer Profile

Company Information

Contact Information

Premium Information

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

Market Information

Additional Documentation