New Agent Profile

If you are not already an agent with AMC, please complete the form below

Agency Name *

Mailing Address

Address *

Address Line 2

City *

State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Postal Code

Street Address

Address *

Address Line 2

City *

State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Postal Code

Contact Information

Owner's Name *

First

Last *

Last

Agency Contact Name *

First

Last *

Last

Email *

Website

Phone *

Fax

FEIN

Accounting Contact Information

Accounting Contact Name *

First

Last *

Last

Email *

Phone *

Fax

Producer Information

Producer Names

Top 3 Companies Represented

Company Names

Company Name

Company Name 2

Company Name 3

Premium

Premium

Loss Ratio

Premium 2

Loss Ratio 2

Premium 3

Loss Ratio 3

Questions

Have you or anyone in your agency had a license suspended or revoked?

Yes

No

Have you ever filed bankruptcy?

Yes

No

Please explain any "yes" answers

Please provide a copy of the following:

• Current Copy of E & O Dec Page or Certificate of Insurance
• Copy of Corporate License or Producer License
• Copy of W-9 Form

Attachments

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