Producer Registration |
| Producers please use the following form to apply as a producer with Commodore Insurance Services, Inc. |
| Agency Name |
|
| First Name |
|
| Last Name |
|
| Physical Address |
|
| City |
|
| State |
|
| Zip |
|
| Mailing Address (if different) |
|
| City |
|
| State |
|
| Zip |
|
| Phone |
|
| Fax |
|
| Email |
|
| Web Site Address |
|
|
| Please select the types of business that you are currently (or interested) writing |
|
|
| Agency Total Property and Casualty Volume: |
| Total Commercial Lines Volume: |
|
| Total Workers Compensation Volume: |
|
| Total BOP Volume |
|
| Total Professional Liability Volume: $ |
|
| Industry Specialization: (if any) |
|
Agency Information |
| Agency Ownership |
|
| Federal Tax ID Number or Social Security Number (if Individual): |
|
| Agents License Number: |
|
| Errors & Omissions Carrier |
|
| Surplus Lines License Number |
|
| Is your agency in a residence? |
|
| Does your agency currently belong to a cluster |
|
| If yes, please List |
|
| Do you broker business for other retail agencies? |
|
| List all states in which you have a non-resident license: |
|
| Do you have an agency management or accounting system? |
|
| If yes, name of software |
|
| Has agency or any principal of the agency ever been subject to any Dept of Inc action regulation violation? |
|
| If yes, attach a detailed explanation of action(s) |
|
| Have there been any E&O claims made against the agency, partners, officers, owners or producers in the past 5 years? |
|
| Has the agency, partners, officers or owners filed, or is in the process of filing, for Bankruptcy in the past 5 years? |
|
| Have any partners, officers, owners or producers ever been convicted of a felony |
|
| Terms of Use |
| |
