Broker Application

Please provide the following information:

  (* Required information.)
Agency Name*:
  
DBA:
  
Contact Name*:
  
Address*:
  
City*:
  
State*:
   Zip*:
Office Phone*:
  
Cell Phone:
  
Fax:
  
E-mail:
  
Website:
  

*Does your Agency have a Premium Trust Account?
Yes No

Please provide name and address of the bank in which you maintain your premium trust account:
bank name:
  
bank address:
  
bank City:
  
bank State:
  
bank Zip:
  
*Does your Agency have an Errors & Omissions
Policy? Yes No
*What are the limits? $
*What's the deductible amount? $
For an E&O policy application, you may contact the Professional Agents Association at www.piaonline.org.
*Does your Agency have Fidelity Coverage?
Yes No
*What are the limits? $
*Your Agency's Estimated Annual Premium Volume:
% Personal Lines   % Commercial
Do you specialize in any classes of business?
If so, specify:

% Retail         % Wholesale
Type of License: Broker   Agent   Both
New York licensees - Read IMPORTANT notice below.
List States of License:
License Number:
Do you Co-Broker any of your Accounts?
Yes No
List the insurers or wholesalers you currently use for placing Commercial Auto and/or Garage business:
How did you initially hear about Lancer Insurance Company's D.C. White division?
Your Comments:

IMPORTANT:
You must hold a resident or non-resident New York Brokers license to place/obtain insurance through our agency. Broker license numbers have a "BR" prefix. New York Agents' licenses have a "PC" prefix. Agent licenses can not be used to place/obtain coverage through insurers which operate on a admitted basis unless the firm is specifically licensed by the insurer as an agent (including placement made through wholesalers)and/or insurers which operate on an excess and surplus lines basis. If you do not have a BR license you can obtain one quickly.This can be acomplished by using the New York State Insurance Department's online licensing system at www.ins.state.ny.us and click on:
1. Agents & Brokers
2. Licensing
3. Producer License Application
4. Property and Casualty Broker (BR)
The Insurance Department will accept a credit card for payment purposes.

         
         
         
         
         
         
     
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
       
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