New Insurance Agent Registration Application

TheIndependentInsuranceAgency.com

We've Made Shopping For Any Kind Of Insurance Coverage Fast, Easy, and Available Online

What It Means to Be a CIC - The Certified Insurance Counselor (CIC) designation is a distinction that represents a commitment to professional excellence and leadership within the insurance industry. The 30,000+ designated CICs across the country are recognized as among the best and most knowledgeable insurance practitioners in the nation. The formal training required to become a CIC includes 100 classroom hours and the successful completion of five comprehensive exams, with an annual update required to ensure that CICs maintain their edge as the most capable and current insurance practitioners in the industry.

Just Complete A Short Online Registration Application To Become A Contracted Agency Producer / Avialable To Qualified Texas Licensed Property & Casualty Insurance Agents Or Licensed Life - Health - Accident Insurance Agents

Our Agency Has Market Access To Many Leading Property & Casualty And Life & Health Insurance Companies

Our producers have access to many property & casualty standard & non-standard A.M. Best "A-" to "A+" Rated insurance carriers for both personal and commercial product lines; with most access being via a single-entry online application for submission to multiple carriers and/or product lines.

Our agencies underwriting staff and managing general agency business partners do the work to determine the right carriers to write your personal & commercial clients and provide you with quick quotes from multiple carriers.

We can consider both large & small accounts. Our underwriters have the experience to write all your accounts from small minimum premium mono-line policy to a multi-million dollar multiple lines commercial account.

Fourteen Good Reasons To Consider Becoming A Contracted Producer With Our Agency

1. P&C Texas Agent License Sponsorship - Available To Qualified Life/Health/Accident (LHA) producers (with a minimum of 2 years LHA insurance industry experience) for a Texas Property & Casualty Insurance Agents License; producers must also agree to meet our agency commitment to achieve professional excellence and leadership within the insurance industry by participating in and completing at least one Certified Insurance Counselor or James Ruble 25 hour educational seminar annually.

2. No Production Commitments - No Minimum Annual Premium or Annual Sales Volume.

3. No Agency Fee - No Fees To Access Our Agency Support Services Or It's Markets.

4. Underwriting Support - Knowledgeable Underwriters & Market Expertise.

5. Online P&C Quoting For Selected Qualified Producers- Available for specific personal & main street classifications with smaller commercial lines accounts once or underwriting carriers have approved a selected producer.

6. Exceptional Agency Producer Training - Regular Weekly In-House Agency Seminars and/or Online Web Training for all Personal & Commercial Lines of Coverage , Professional Sale Presentations , Industry Classification & Underwriting Requirements, Carrier Appetite By Industry Class, and many other producer training related topics.

7. Field Sales Support - Certified Insurance Counselor's Will Assist You During Sales Presentations To Larger Commercial Lines Accounts.

8. Customer Service Support - Once you have made the sale our agency customer service team will provide customers with professional management of all routine services issues; related to billing , policy issue follow-up , additional / deletions of vehicles or drivers, Texas Auto Liability ID Card Issuance , Issuance Of Certificate of Insurance , claim reporting or submission to insurance companies, loss runs , and many other such daily service activities.

9. Quick P&C Quote Request With 24 to 48 Hour Turn-Around - on most fully completed application submissions.

10. Technology & General Producer Sales Tools/Leads - Sales Brochures & Carrier Approved Marketing Materials , Agency Producer Business Cards , Agency Email ( producers name@theindependentinsuranceagency.com ) , Technology support including but not limited to online quote request accessibility and agency web site internet generated sales leads for personal and commercial lines customer located within your service area.

11.Accounts Of All Sizes - Our agency can help our producers write any size account; from the smallest employer with only a mono-line minimum premium account need to the larger employer with multiple insurance needs involving many lines of coverage (including most domestic , foreign , offshore , or marine risk exposures) that may generate many millions of dollars in annual premium.

12. Contracted Producers May Receive An Equal Share Of Agency Commissions - In Most Cases Up to 50% Of The Agencies 1st Year and Ongoing Renewal Commissions ;so long as such agent remains contracted with the agency and his business stays in force through our agency . Renewal Commissions are vested for up two years in the event either party wishes to terminate the producer agreement; unless such agreement is terminated for cause due to a revoked / suspended / terminated insurance license , breach of contract ,conviction of an act fraud , conviction of a crime punishable as a felony , or any act of moral turpitude.

13.Individual Health Insurance Instant Online Quotes & Application Submission - Your customers may instantly compare plans & rates on a spread sheet format basis with most major insurance carriers , compare rates & plan features for up to 100 + plans in just minutes, download plan brochures along with required outlines of coverage, perform online PPO Network provider searches, and submit online insurance application directly to the insurance company underwriters with most insurance carrier plans represented.

14. Competitive Rates - Since our agency has market access to many insurance carriers and products our producers may consistently offer their clients " best of class" coverage from multiple carriers with very competitive rates; as a result our producers enjoy a greater percentage of sold new business accounts.

New Producer / Insurance Agent Online Registration Application

(This information will be keep strictly confidential; it will not be released to anyone without your express prior written consent)

Enter Your Agent License Number:

State

Number

Type Licenses: Life/Health/Accident Property & Casualty

If Other Please Specify:

Full Name ( As appears on your Agent License)

Address ( As appears on your Agent License)

City ( As appears on your Agent License)

State ( As appears on your Agent License)

Zip Code ( As appears on your Agent License)

Private Contract Tel. #

(Area Code) 000-0000

Private Fax Tel. #

(Area Code) 000-0000

Personal Cell/Mobile Tel. #

(Area Code) 000-0000

Email Address

Mail Address Same As Address Above

Yes No ( If " Yes " skip mail address section below )

Mail - Address

Mail - City

Mail - State

Mail - Zip Code

I Am A Currently Active Licensed Insurance Agent Seeking A Contract & Appointment To Represent Your Agency As:

I am a licensed Life/Health/Accident (LHA) agent requesting sponsorship for my P&C insurance license (minimum of 2 years prior LHA Agent experience required).

I am a licensed Property/Casualty agent seeking access to additional insurance markets for:

1. All Lines

2. Personal Lines: Standard Non-Standard

3. Commercial Lines:Standard Non-Standard

I am a licensed P&C insurance agent requesting sponsorship for my Life/Health/Accident insurance license.

I am a licensed Life/Health/Accident agent seeking access to your agencies online multiple carrier quoting systems and markets for:

Individual Health Insurance PlansSmall Employer Group Health Plans Both Individual & Small Group

Which Insurance Companies Are You Currently Appointed To Represent ?

Please Provide Details For You Top Three Life / Health / Accident Insurance Carriers

Name Of Insurance Company

Current Annual Premium Volume

# Individual Cases/ # Group Cases

Please Provide Details For You Top Three Property & Casualty Insurance Companies

Name Of Insurance Company

Current Annual Premium Volume

Loss Ratio ( Premium vs. Claims )

Please Provide Us With Your Errors & Omissions Insurance Coverage Information Below

Insurer's Name

Effective Date

Expiration Date

Occurrence Coverage Limit

Aggregate Coverage Limit

Policy Form

Claims MadeOccurrence

Has your agency ever had an E & O claim?

Yes No

If " Yes" Please Briefly Explain :

Do you inspect all policies and endorsements for accuracy

Yes No

If appointed as a P&C producer do you agree to inspect all insured premises prior to insuring coverage?

Yes No

Please email edhemphill@theindependentinsuranceagency.com or fax 936-448-1013 us a copy of your current E&O Declarations Page

Please Provide US With Your Insurance Background Information

EXPLAIN ALL "YES" RESPONSES. PROVIDE COMPLETE DETAILS AND ATTACH APPROPRIATE DOCUMENTS (e.g., Official Court Records).

1. HAVE YOU FILED FOR, OR BEEN DISCHARGED FROM ANY BANKRUPTCY (INCLUDING PERSONAL BANKRUPTCY), INSOLVENCY OR ASSIGNMENT FOR THE BENEFIT OF CREDITORS WITH A FILING OR DISCHARGE DATE, WHICHEVER IS LATER, IN THE LAST FIVE (5) YEARS?	Yes No
2. DO YOU HAVE DELINQUENT UNPAID DEBTS EXCEEDING, IN TOTAL, $10,000? (ADD TOGETHER DELINQUENT: CONSUMER DEBT, TAX LIENS, LOANS, CHILD SUPPORT PAYMENTS, ALIMONY PAYMENTS, CIVIL JUDGMENTS, AND OTHER DELINQUENT DEBT.	Yes No
3. WITH THE EXCEPTION OF SITUATIONS SPECIFIC TO CONTINUING EDUCATION, HAVE YOU EVER BEEN THE SUBJECT OF AN ADMINISTRATIVE PROCEEDING REGARDING ANY PROFESSIONAL OR OCCUPATIONAL LICENSE THAT RESULTED IN DISCIPLINARY ACTION?	Yes No
4. WITH THE EXCEPTION OF SITUATIONS SPECIFIC TO CONTINUING EDUCATION, HAS YOUR INSURANCE LICENSE EVER BEEN SUSPENDED BY, SUBJECT TO A CONSENT ORDER FROM, REVOKED BY, OR SURRENDERED TO, ANY REGULATORY AGENCY, OR HAVE YOU EVER BEEN FINED, PENALIZED, SANCTIONED OR SUBJECT TO ANY OTHER DISCIPLINARY ACTION BY A STATE OR FEDERAL REGULATORY AGENCY OR SELF REGULATORY ORGANIZATION OR ARE YOU CURRENTLY UNDER INVESTIGATION AS A RESULT OF YOUR ACTIVITIES IN THE BUSINESS OF INSURANCE, SECURITIES, BANKING, INVESTMENT BANKING OR REAL ESTATE?	Yes No
5. HAVE YOU EVER HAD AN INSURANCE AGENCY CONTRACT OR ANY OTHER BUSINESS RELATIONSHIP WITH AN INSURANCE COMPANY TERMINATED FOR ANY ALLEGED MISCONDUCT?	Yes No
6. HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY OR NO CONTEST TO, OR ARE YOU CURRENTLY CHARGED WITH OR UNDER INVESTIGATION FOR ANY MISDEMEANOR INVOLVING DISHONESTY OR BREACH OF TRUST OR ANY FELONY?	Yes No
7. ARE YOU NOW THE SUBJECT OF ANY COMPLAINT, INVESTIGATION, OR PROCEEDING THAT COULD RESULT IN A "YES" ANSWER TO ANY OF THE PREVIOUS QUESTIONS?	Yes No
Please Provide A Brief Response In The Below Remarks Section To Any Background Question 1 through 7 Which You Answered "YES" To : REMARKS: :
I HEREBY CERTIFY THAT ALL OF THE INFORMATION HEREIN IS ACCURATE AND COMPLETE. I ACKNOWLEDGE AND AGREE THAT MY APPOINTMENT WILL, IN PART, BE BASED ON THIS PRODUCER APPOINTMENT FORM AND BACKGROUND INFORMATION, AND ANY FALSIFICATION, MISREPRESENTATION OR OMISSION OF INFORMATION FROM THIS FORM MAY RESULT IN THE WITHHOLDING OR WITHDRAWAL OF ANY OFFER OF APPOINTMENT OR THE REVOCATION OF APPOINTMENT Or PRODUCER CONTRACT BY THE AGENCY WHENEVER DISCOVERED.
e-SIGNATURE You are hereby certifying that you are in fact the actual individual natural person who typed your name in the above e-SIGNATURE box and that you have truthfully provided all the information contained on the above electronic new producer / agent online registration application	Date:MM/DD/YYYY

Click Here To Download , Print , & Submit A Signed ACORD 818 Producer Background Form - Required Upon Final Approval Of Your Online Application

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