New Active Satellite Office Request

A. Satellite Office Information

Agency Name (Legal Name)(Required)

DBA

Phone(Required)

Accounting Statement Email(Required)

Other Associations(Required)

If YES, please list(Required)

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)

Agency Contacts

Name	Position	Email	Principal Contact	Actions

There are no Contacts.

Main Office Agency Name(Required)

W-9(Required)

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

Full E&O Policy

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

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Agency License(Required)

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

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Principal License(Required)

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

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Cyber Liability Policy

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

Completed By(Required)

Title(Required)

Date(Required)

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M&A