New Agency Appointment Profile
* denotes required field
Producer Details
Legal Entity Name: *
Federal Tax ID:
Agency / Brokerage License Number: *
States in Which Agency /Brokerage is Licensed: *  
Street Address: (Main or Headquarters Location)
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Mailing Address: (Main or Headquarters Location)
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Billing Address:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Main or Headquarters Location Phone Number: *
Additional business locations (list states if more than 1 or 2 additional locations)
Street Address: (Location 2)
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Mailing Address: (Location 2)
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Location 2 Phone Number:
Street Address: (Location 3)
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Mailing Address: (Location 3)
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Location 3 Phone Number:
Website: *
Year Agency Established: *
Publicly or Privately held? *
If public input trading name:
Total Agency Revenue – all locations: *
Total Agency Commercial Lines Premium: *
Premium Mix:
Commercial %:
Personal %:
Employee Benefits %:
Other %:
Explain:
Total Number of Employees: *
Total Number of Commercial Producers /Brokers: *
Wholesale or Retail? *
Is Agency / Broker part of an alliance, cluster, network or other aggregator?: *
If Yes, please be specific:
How did you hear about us: *
Ownership / Executive Management
     
Owner Id First Name Last Name Title Percent Email Phone No Order No
    
Key Administrative Contacts
     
Id First Name Last Name Title Position Email Phone No Required Order No
Accounting/Billing
Agency Licensing
Automation
Claims Manager
Customer Service Manager
    
Key Production Contacts
     
Id First Name Last Name Title Position Email Phone No Required Order No
Marketing Manager
Marketing Specialists
Producers/Brokers
    
Top Commercial Lines Carriers
CarrierId Carrier Name * Premium Written * Loss Ratio% * Predominate Products Written * Order No
    
Commercial Insurance Products
     
Id Insurance Products Do You Write? Premium Volume Estimated Predominate Carrier Predominate Office Location Main Product Contact Required Order No
Life Sciences
Environmental
Excess Casualty/Umbrella
Inland Marine
Global/Foreign Package
Management Liability – Publicly and Privately Traded Companies
Marine Blue Water Hull
Ocean Cargo
Accountants Professional Liability
Technology Professional Liability
Cyber Liability
Miscellaneous Professional Liability
Marine Liability Products
Architects & Engineers Liability
Surety
    
If Wholesale Broker please answer the below as well:
     
Id Insurance Products Do You Write? Premium Volume Estimated Predominate Carrier Predominate Office Location Main Product Contact Required Order No
Specialty Primary General Liability
Construction Wrap-Up General Liability Coverage
    
Percentage of Commercial Premium in the following general Industries:
Industry Percentage Industry Percentage Industry Percentage
Agriculture Life Sciences Real Estate
Contracting Manufacturing Technology
Energy Professional Services Transportation
Healthcare Retail Wholesale
Beverage & Tobacco Financial Services Legal Service
Entertainment Freight Forwarders
What areas of specialization or expertise does your agency actively market? *
Do you have any Niche Programs or Industry Practices/Verticals? *
Navigators Opportunity
Where do you feel Navigators will have the most opportunity for growth with your agency/brokerage?: *
Required Documentation
We require that you provide us with evidence of your agency's Errors and Omissions Liability coverage.

Please note that Navigators reserves the right to request any additional documentation or information that we feel necessary for a satisfactory review of your application.
Instructions
If you have a contact at Navigators to whom you would like to direct this, please print this form, sign it and return it together with copies of all required documentation.
If you would like someone at Navigators to contact you, please fill in the fields below, click “Submit” and someone will be in touch with you shortly.
Your Name: *
Your Title: *
Your Email: *
By clicking below, I certify that the information contained in this New Agency Appointment Application is complete, true and accurate.
Thank you for your interest and we look forward to working with you.
Copyright 2008. All Rights Reserved. The Navigators Group, Inc.