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), insurers which operate on an excess and surplus lines basis or residual markets. If you do not have a BR license you can obtain one quickly by using the New York State Insurance Department's on line licensing system found at www.ins.state.ny.us.
         
         
         
         
         
         
     
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
   
   
   
     
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