New Agent – U.S. "*" indicates required fields Agency Name* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Fax NumberHow long in business?* Email* Key Agency PersonnelName* First Last License Number* Years of Experience* Position* Annual Premium VolumeTotal Volume All LInes Producers How many producers do you have?Top Three Companies RepresentedCompany 1 Name* Company 1 C/L Volume* Company 1 Loss Ratio - 3 Yr.* Company 2 Name Company 2 C/L Volume Company 2 Loss Ratio - 3 Yr. Company 3 Name Company 3 C/L Volume Company 3 Loss Ratio - 3 Yr. Bank InformationPlease place the name and address of the bank where your premium account is maintained.Bank Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Annual VolumesApproximate Annual Premium volume you now write for each category.Group Captives Single Parent Captives Large Deductibles Largest Account Total Premium Largest Account Industry Type Do you maintain E&O Insurance?* Yes No Has your company withdrawn from your agency in the past three years?* Yes No Has your company cancelled or refused to renew your E&O policy?* Yes No In which states are you licensed for P/C? AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What geographical areas will you cover, and how do you plan to use and market the lines provided by eMaxx Insurance Services, LLC?Agreement* "I acknowledge that the above information has been disclosed to me. I declare that all statements made above are true to the best of my knowledge" Subscribe to join our newsletter! Yes, I would love to subscribe to the eMaxx Newsletter! PhoneThis field is for validation purposes and should be left unchanged. Latest News20 days to the Risk Management Summit30 day countdown to the Risk Management Summit, Register and Book your hotel13 Questions for Brian McCarthy, CEO of the eMaxx Assurance Group of CompaniesPress Releases30 day countdown to the Risk Management Summit, Register and Book your hotelSeptember 15, 202313 Questions for Brian McCarthy, CEO of the eMaxx Assurance Group of CompaniesSeptember 11, 2023Captive Insurance ProgramsJuly 25, 2023On The BlogYom Kippor wishesHappy Rosh HashanahHow Does Captive Insurance Work Join Our Newsletter Success! Email Sign Up Report a Claim Contact Us FollowFollowFollowFollow
