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We look forward to learning more about your agency. Please complete the form below to initiate the review process (or, you can use this PDF form and email to us).

Your information

Your Name*

First Last

Title*

Phone*

Mobile

Fax

Email*

IMPORTANT: You'll receive a copy at this email

Agency information

Agency Name*

DBA

Business Type*

Broker
Agency

FEIN

Federal Employer Identification Number. Must be exactly 9 digits with no dash or spaces and must not be all 9s or all 0s.

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address*

Mailing Address is the same as Physical Address

Street Address Address Line 2 City State ZIP Code

Workers' compensation market

Work Comp volume: $*

Work Comp accounts*

Number of accounts	Number below $25K

Number of producers*

List the states you predominantly do business in.*

Carrier information

Please account for 90% of premium volume. Production reports are required prior to appointment.*

Carrier	Premium: $	# of accounts	5-year Loss Ratio

Wholesale relationships

List wholesalers used for workers' comp line and what ICW Group volume, if any, that you have with them.

Wholesaler	Current volume $	# of accounts

Are you a member of a cluster (network of independent insurance agency partners)?*

No
Yes

Please explain

Is your agency affiliated with any other insurance carrier? (i.e. State Farm, Farmers)*

No
Yes

Please explain

Book of business profile

Does your agency specialize in a specific industry?*

No
Yes

Please explain

Principals

Check this box if you are a principal, to copy your information from above.

Check this box if you are a principal, to copy your information from above.

Principals*

First Name	Last Name	Title	Phone	Email

Agency contract signator

Who at your company will be approving this appointment?

Check this box if you are the approver, to copy your information from above.

Check this box if you are the approver, to copy your information from above.

Signator Name*

First Last

Title*

Phone*

Email*

Who referred you?

Comments

This field is for validation purposes and should be left unchanged.

Start your ICW Group agent application

Your information

Agency information

Workers' compensation market

Carrier information

Wholesale relationships

Book of business profile

Company information

Principals

Agency contract signator