Application Form | Arlington/Roe

A. Agency Information

Agency Name (Legal Name)(Required)

DBA

Phone(Required)

Agency Statement Email(Required)

Number of Employees(Required)

Please enter a number greater than or equal to 1.

Website

Year Business Established(Required)

Agency Management System(Required)

Other Agency Management System

B. Premium Volume Distribution

Total Premium Volume: $(Required)

Of your total annual premium, what is the approximate division between:

Total Personal Lines Premium Volume : $(Required)

Total Commercial Lines Premium Volume: $(Required)

Standard Lines Carriers you do business with:

Total Standard Carrier Volume: $(Required)

Standard Lines Carriers

Company	Personal Lines Premium Volume ($)	Commercial Lines Premium Volume ($)	Actions
@nbsp;	@nbsp;	@nbsp;
There are no Carriers.

Enter at least three standard carriers. If you are not contracted with at least three standard carriers, please use ‘N/A’ for the company name for any remaining carrier selections.

List Excess & Surplus Brokers of Managing General Agents you do business with:

Total Excess and Surplus Lines Brokers Volume: $(Required)

Excess and Surplus Lines Brokers

Company	Personal @amp; Commercial Premium Volume ($)	Actions
@nbsp;	@nbsp;
There are no Brokers.

Minimum 1

How much premium volume will your agency be able to commit to Arlington/Roe during our

FIRST YEAR of doing business together?(Required)

Please enter a number greater than or equal to 0.

in $ value

SECOND YEAR of doing business together?(Required)

Please enter a number greater than or equal to 0.

in $ value

If YES or MAYBE please explain(Required)

C. Agency Background

Other Associations(Required)

Other Agency Entity(Required)

Please Explain (Cancellation)(Required)

Please Explain (Suspension)(Required)

Please list finance company used(Required)

How were you referred to Arlington/Roe?(Required)

W-9(Required)

Accepted file types: pdf, Max. file size: 60 MB.

Agency License(Required)

Accepted file types: pdf, Max. file size: 60 MB.

Principal License(Required)

Accepted file types: pdf, Max. file size: 60 MB.

Full E&O Policy(Required)

Accepted file types: pdf, Max. file size: 15 MB.

Cyber Liability Policy

Accepted file types: pdf, Max. file size: 60 MB.

Agency Contacts

Name	Position	Email	Principal Contact	Actions
@nbsp;	@nbsp;	@nbsp;	@nbsp;
There are no Contacts.

Completed By(Required)

Title(Required)

Date(Required)

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M&A

Producer Application & Documentation

A. Agency Information

B. Premium Volume Distribution

C. Agency Background