Step 1 of 9 11% Legal Name(Required) Mailing Address(Required) 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 Is Your Physical Address The Same As Your Mailing Address?(Required) Yes No Mailing Address(Required) 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 FEIN(Required) Agency Name as Licensed and as it should appear on agreement:(Required)Agency Principal(Required) Phone(Required)Fax(Required)Agency URL/Website Address(Required) Email(Required) Agency Type(Required) Corporation Partnership Individual Other Date Established(Required) MM slash DD slash YYYY Please tell us about your key personnel (Partners, President, Vice President, Secretary, Treasurer, etc.)(Required)Officers Name & Title% OwnershipTime Employed With AgencyLicensed States Add RemoveHave any of your key personnel ever been convicted of a felony or misdemeanor? If “yes”, please explain(Required)Has an insurance company cancelled it's connection with your agency in the last 3 years, if yes please explain(Required) List All Agency Locations(Required) Add Remove(Full Address)List all Licensed Personnel(Required)NameSocial Security #TitleLocation (from above) Add Remove(please include copies of corporate and individual state license) Does this agency maintain a separate banking account for all collected insurance premiums?(Required) Yes No Please provide the financial institutions’ names and addresses below:Has your agency ever been investigated by the Department of Insurance?(Required) Yes No What were their findings?Have all recommendations and requirements been complied with?(Required)Errors and Omissions Carrier and Policy Limit (attached a copy of the current policy’s dec page):(Required) File Drop files here or Select files Max. file size: 5 MB, Max. files: 5. Does your agency have an agency management system?(Required) Yes No Please indicate the type of automation system:Please explain your current Perpetuation Plan. Please attach the plan if you have it documented:(Required)File Drop files here or Select files Max. file size: 5 MB, Max. files: 5. Please explain your agency’s interest in obtaining a membership with Total Insurance Plus:(Required) Agency Premium Profile - Top 7 Carriers:(Required)Company NameTotal Premium Value% Commercial% Personal Add RemoveDo you accept brokerage business?(Required) Yes No Please explain:Classification of Total Agency Business. Annual Volume Last Year:(Required)Total $Personal Lines $Commercial Lines $ Add Remove Total Insurance Plus – Aggregated Carriers - Please note if you are interested in aggregating a current book of business or becoming appointed with a listed carrier.Accident Fund List Aggregation Desired & Appointment DesiredAmWins List Aggregation Desired & Appointment DesiredBuilders Mutual List Aggregation Desired & Appointment DesiredBerkley Southeast Ins Group List Aggregation Desired & Appointment DesiredCentral Insurance List Aggregation Desired & Appointment DesiredDonegal List Aggregation Desired & Appointment DesiredEmployers List Aggregation Desired & Appointment DesiredFirst Benefits Insurance Mutual List Aggregation Desired & Appointment DesiredForemost List Aggregation Desired & Appointment DesiredFrankenmuth Insurance List Aggregation Desired & Appointment DesiredGuard Insurance List Aggregation Desired & Appointment DesiredHarford Mutual Insurance List Aggregation Desired & Appointment DesiredThe Hartford List Aggregation Desired & Appointment DesiredJackson Sumner (JSA) List Aggregation Desired & Appointment DesiredJohnson & Johnson List Aggregation Desired & Appointment DesiredLiberty Mutual List Aggregation Desired & Appointment DesiredNationwide Mutual Ins Co List Aggregation Desired & Appointment DesiredPhiladelphia Insurance Co List Aggregation Desired & Appointment DesiredRT Specialty List Aggregation Desired & Appointment DesiredSafeco List Aggregation Desired & Appointment DesiredSouthern Mutual Church Ins Co List Aggregation Desired & Appointment DesiredState Auto List Aggregation Desired & Appointment DesiredTAPCO List Aggregation Desired & Appointment DesiredTravelers List Aggregation Desired & Appointment DesiredUnited Heartland List Aggregation Desired & Appointment DesiredUtica List Aggregation Desired & Appointment DesiredWest Bend List Aggregation Desired & Appointment Desired Additional Items Required for a Complete Submission:- Copy of current Errors & Omissions declarations page - Most recent annual Production Reports (including 3 year loss runs) for all carriers – most importantly your top 7 carriers as well as any carriers you would like to aggregate with Total Insurance Plus - Agency Perpetuation Plan, if your agency has it in writingUpload Files Drop files here or Select files Max. file size: 5 MB, Max. files: 10. Signatory Declaration:All statements and representations of the above completed application for membership consideration are true to the best of my knowledge and belief at the time of submission. I understand that Total Insurance Plus is relying upon my above material representations regarding the agency’s vitality and performance to determine admission of my agency as a member.Name(Required) First Last This will serve as an electronic signature for this document.Date(Required) MM slash DD slash YYYY hCaptcha(Required)
