Thank you for your interest in working with RIC Insurance General Agency, Inc. In order to be appointed with RIC, you must be a licensed insurance Broker / Agent and carry errors & omissions insurance coverage. Please complete the Producer Data Sheet. This will take approximately 10-15 minutes. All information will be kept confidential. Agency Owner / Principal Name* First Last Agency DBA*Agency Corporation Name*Legal Entity*Click to SelectIndividualPartnershipLLCCorporationExclusive Agency?*Click to SelectAllstateFarmersOtherIf Allstate, Allstate Agent #Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address (if different from above) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Cell Phone*Fax* Agent License Number*Expiration Date* MM DD YYYY Agency License Number*Expiration Date* MM DD YYYY E&O Coverage Carrier*Expiration Date* MM DD YYYY What additional states is your agency licensed to write business in?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBroker Bond Filed*YesNoNumber of Years in Business* What is the approximate premium size of your agency?*Of your total agency production, what percentage is personal lines?*When added to Commercial Lines, Total Agency Production should equal 100%.Please enter a number from 0 to 100.Of your total agency production, what percentage is commercial lines?*When added to Personal Lines, Total Agency Production should equal 100%.Please enter a number from 0 to 100.Who makes decisions about which markets to use?* Producers CSRs Other Active producers your agency has*Classes of business your agency specializes in*Which carriers do you work with on a direct basis for commercial lines?*Which carriers do you work with on a direct basis for personal lines?*Which General Agencies (GAs) and Wholesalers do you currently work with?*Does your agency write Surplus Lines business?*YesNoWhich Surplus Lines brokers do you work with?What has your experience been with the key GAs/Surplus Lines brokers that you are currently using?ExcellentGoodBad What is most important to you in building a partnership with RIC?*Agency Contact InformationAgency Contact* First Last Agency Email* This should be the email address for the person who receives any and all email correspondence relating to this submission. S/he would then forward any emails received from RIC as needed.Correspondence Preference* Email Fax Please indicate how you would like to receive notifications on cancellations, endorsements, commission statements, etc.Application Completed By:* First Last Title*HIDDEN FIELD / NOT WORKING ON FRONTEND. Please attach copies of licenses, E&O and bond. These will be required to move forward with the appointment process.Accepted file types: jpg, pdf, doc, docx, xls, xlsx.If licensed in more than one state, please attached copies of agent and agency licenses. If an Allstate Agent, please include the CEM (Commercial Expanded Market) course completion certificate. Upload limit: 128MB.Please attach copies of licenses, E&O and bond. These will be required to move forward with the appointment process.* Drop files here or Accepted file types: jpg, pdf, doc, docx, xls, xlsx. If licensed in more than one state, please attached copies of agent and agency licenses. If an Allstate Agent, please include the CEM (Commercial Expanded Market) course completion certificate. Upload limit: 128MB. File types allowed: jpg, pdf, doc, docx, xls, xlsx
