User account

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Agency Information

Agency Name: *

Year Established: *

License Number: *

Licensed States: *		Order

Provide a copy of Agency/Producer's License: *

Tax ID or SSN: *

Total Number of Producers: *

Total Agency Staff: *

Principal's Name: *

Principal's Title: *

Mix of Business

Construction: %

Mercantile: %

Hospitality: %

Health Care: %

Automotive: %

Food / Agricultural: %

Manufacturing (all types): %

Professional: %

Other: %

Worker's Compensation Experience Summary

Please provide a complete list of Carriers, Written Premiums, States and 3 Year Loss Ratio: *		Order
	Carrier: Written Premiums: States: 3 Year Loss Ratio:

Contact Info

Phone: *

Please include your area code.

Fax:

Please include your area code.

Website:

Physical Address

Address: *

City: *

State: *

Zip Code: *

Mailing Address (if different)

Address:

City:

State:

Zip Code:

Check all that apply

The agency, shareholder, partner or principal thereof has at some time declared bankruptcy

The agency, shareholder, partner or principal thereof has at some point been convicted of a felony.

The agency shareholder, partner or principal thereof has been refused a license in any state.

The agency, shareholder, partner or principal has been subject to discipline or investigated by the Department of Insurance.

The agency acts as a wholesaler or appoints subproduction sources.

Please explain any checked items above:

Errors & Omissions Insurance Coverage

Amount of E&O Coverage: * $

Provide a copy of Agency's E&O Declarations Page: *

The agency has had E&O claims, complaints filed with regulatory authorities or license revocations in the past 5 years.

Please explain if above item is checked:

Applicant Information

Applicant Name: *

Applicant Title: *

Applicant must be a Principal or Officer.

Date: *

Legal

Legal Declaration: *

The information provided is both accurate and complete. I am an Officer or Principal of the applying agency, and am an authorized signatory. I certify that materials made available to approved producers will be exclusively used for producer functions for Atlas General Insurance Services, and will not be used in any other manner or disseminated outside the applying agency.

Atlas General Insurance Services, Inc.

User account