Become An NIA-Appointed Broker Questionnaire

Agency Information

Agency Name

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Agency Email

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Phone Number

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Street Address

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City

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State Located

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Postal Code

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County

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Country

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Website

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Primary Contact Information

First Name

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Last Name

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Title

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Email

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Phone Number

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Additional Details About Your Brokerage:

Total Premium Written

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Total 501(c)(3) Nonprofit Accounts (excluding churches & hospitals)

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% Commercial Lines

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% Personal Lines

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Number of Producers

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Number of Producers Writing Nonprofit Business

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What markets do you currently use to place nonprofit business?

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If you are part of an Insurance Agency Network/Consortium, please specify

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If you write nonprofit business with wholesalers, please specify

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Has your agency or any principal at your agency ever had a license revoked?

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Yes

No

Has your agency been cancelled by any insurer in the last 5 years?

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Yes

No

Are you aware of any pending disciplinary action by DOI?

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Yes

No

Has your agency received any disciplinary action by the DOI?

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Yes

No

Any pending/threatened litigation in past 5 years?

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Yes

No

Any circumstances that may reasonably give rise to a claim?

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Yes

No

If you answered "Yes" to any of the questions above, please explain

In which states does your agency hold valid licenses?*

Please note: To write business in Florida, we will refer you to a wholesaler.

Accuracy Acknowledgement

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I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Print Name

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Date

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