1
Agency
2
Producer
3
E&O
4
Business
5
Review
Step 1 Agency Information
Business Name
*
Business Owner
*
Business Owner Date of Birth
*
Business Legal Entity Type
*
Select
Corporation
LLC
Partnership
Sole Proprietorship
Business Tax ID
*
Street Address
*
Street City, State, Zip
*
Select
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
DC
County
*
Use Street Address for Mailing Address
Business Mailing Address
Mailing City, State, Zip
Select
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
DC
Phone
*
Fax
Email
*
Website
Year Business was Formed
*
Step 2 Producer Information
Primary Producer
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Secondary Producer (Optional)
First Name
Middle Name
Last Name
Date of Birth
Step 3 E&O Information
Errors and Omissions Carrier
Select
Acord
Admiral Insurance Company
American Automobile Insurance Co
American Safety Casualty Insurance Company
Arch Insurance Company
Argonaut insurance Company
Axis Insurance Company
Berkley Assurance Company
Brown & Brown Program Insurance Services Inc
Catlin Specialty Insurance Company
Century Surety Company
Certain Underwriters at Lloyd's of London
CITA Insurance Services
Colony Specialty Insurance Company
Darwin National Assurance Company
Darwin Select Insurance company
Endurance American Specialty Insurance Co
Essex Insurance Company
Everest National Insurance Company
Executive Risk Indemnity Inc
Fireman's Fund
First Specialty Insurance Corporation
General Insurance Company of America
General Star Indemnity Ins Co
Greenwich Insurance Company
Indian Harbor Insurance Company
Insurance Intermediaries Inc
iWorld Financial Group
Landmark American Insurance Company
Lexington Insurance Company
Liberty Agency Underwriters
Liberty Insurance Underwriters Inc
Liberty Mutual
Lloyds of London
Lockton Companies, LLC - 1 Kansas City
Maxum Indemnity Company
Mount Vernon Fire Insurance Company
Namico Insurance
Navigators Insurance Company
Professional Underwriting Group Inc
Savers Property & Casualty Insurance Company
Scottsdale Indemnity Company
U.S. Risk Inc
Underwriters at Lloyds of London
United States Liability Insurance Company
US E&O Brokers
UTICA Mutual Insurance Company
Utica National Insurance Group
Westport Insurance Corporation
XL Insurance
Zurich American Insurance Company
Other (Not Listed)
E&O Policy Number
E&O Policy Effective Date
E&O Policy Expiration Date
Limit of Liability (Policy Limits at least $1,000,000)
Each Claim
Select
100,000
500,000
750,000
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
Other (Not Listed)
Aggregate
Select
100,000
500,000
750,000
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
Other (Not Listed)
Deductible (Not greater than $25,000)
Each Claim
Select
1,000
1,500
2,500
3,000
5,000
7,500
10,000
15,000
20,000
25,000
30,000
40,000
50,000
125,000
150,000
250,000
500,000
1,000,000
Other (Not Listed)
Aggregate
Select
1,000
1,500
2,500
3,000
5,000
7,500
10,000
15,000
20,000
25,000
30,000
40,000
50,000
125,000
150,000
250,000
500,000
1,000,000
Other (Not Listed)
Step 4 Business Information
Years of Insurance Experience?
*
Select
0-2
2-5
5-10
10+
Is your agency a member of a Group or Aggregator?
*
Select
Yes
No
Does your agency currently write business with National General through a broker?
*
Select
Yes
No
Which National General Product are you most interested in writing?
*
Select
Personal Auto
Homeowner
Commercial Auto
Motorcycle
Recreational Vehicle
Dwelling Fire
Package
Flood
Comparative Rater
*
Select
None
AccuAuto
ACS
Applied
Atlatl
BOLT
Catalyst
CCI Computer Services
EZLynx
FSC - StoneRiver
IBQ
InsurQuote
Insurun
ITC
Jenesis
PL Rating
QQ Catalyst
QuickQuote
Quinstreet -QRP
Quomation
QuoteRush
Single Point
Transformation Station
United Software – USD
Other (Not Listed)
Agency Management System
*
Select
None
Accuagency
Agency Advantage
Agency Impact
Agency Matrix
Agency Software
Agency Solution
Agency Systems
Agency Technolgy
Agentcubed
Agents Choice
Ams
Applied
Appone
Assurance
Better Agency
Brooke Corp
Cair
Cim-data
Cloudams
Cssi
Doris
E Bridge Solutions
Ebix
Ebridge
Edi Concepts
Evolution
Fsc
Gbs
Harte
Hawksoft
Impowersoft
Ins.automation
Instar
Irs-aims
Itc
Jenesis
Jenesis Software
Keal Technology
Keepthemsmiling
Mass Ins Systems
Mi Assistant
Mmis
Nasa
Nexus Linx
Nowcerts
QQ Catalyst
Quick Quote
Quikfuzion
Quomation
Record Guardian
Sentry Ims
Sis
Span2
Special Agent
Stone River
Sunrise Ins Systems
Tam Of Canada
Tech Canary
Terrace
Veruna
Vrc Insurance System
Webcetera
Xanatek
Xdti
Zycomp
Other (Not Listed)
#
Companies Represented
Lines of Business
Annual Premium
LossRatio
1
*
Select
A Central
AAA
ACCC Insurance
Access Insurance Company
Adirondack Insurance Exchange
Affirmative Insurance
Agency Insurance Co of Maryland
Aggressive Insurance
AGIC Insurance Company
AIC - Agency Insurance Co
Alfa Alliance
Alliance Mutual Ins Co
Alliance United
Allied
Allstate Insurance
American Commerce Ins Co (ACIC)
American Modern Insurance Grp
American Southwest
AmTrust Ins Co
Anchor General
Arrowhead General
Assigned Risk Plan
Assurance America
Assurant Group
Auto One
Auto-Owners Insurance Group
Bankers Insurance Group, Inc
Beacon Insurance Group
Brethren Mutual Insurance Co
Bristol West Insurance Group
Builders Mutual Insurance Co
Canal Group
Central Insurance Companies
Central Services Group
Century-National Ins Co
Chubb Group of Insurance Cos
Cincinnati Insurance Cos
Commerce Group Inc
Consumers Insurance USA, Inc
Countryway Insurance
Country-Wide Insurance Co
Dairyland
Discovery Insurance Company
Donegal Group
EMC Insurance Companies
Encompass
Equity Mutual Insurance Co
Erie Insurance Group
Eveready Insurance Company
Everest Re U.S. Group
Explorer Insurance Company
Farmers Alliance Companies
Farmers Mutual Ins Co of NE
Fidelity National Group
Foremost
Gainsco
General Casualty Ins Co
Georgia Mutual Insurance
Grain Dealers Mutual Ins Co
Granada Insurance Company
Grange Mutual Casualty Group
Grange Mutual Ins Co (OR)
Greenville Casualty Ins Co
GuideOne Insurance
Hallmark Insurance Company
Hanover Insurance
Harford Mutual
Harleysville Insurance
Hartford Insurance Group
Haulers Insurance Company, Inc
Imperial Fire & Cas Ins Co
Infinity
Innovative Value-MGA
Instrust Insurance
InsureMax Insurance Company
Interboro Mutual Indem Ins Co
Kemper Insurance Companies
Kingsway Amigo Ins Co
Legacy
Liberty Mutual Insurance Cos
Lincoln General
Lititz Mutual Group
Loudoun Mutual Ins Co
Main Street America Group
Mapfre Corporation of Florida
Mendota Insurance
Mercury General Group
MetLife P&C
Montgomery Insurance
Motorists Insurance Group
Mutual of Enumclaw Insurance
National Grange
National Security Group, Inc
Nationwide Group
NC Grange Mutual Ins Co
Northern Neck Insurance Co
NY Central
Occidental Fire & Casualty Ins Co
Ocean Harbor Casualty Ins Co
Ohio Casualty Group
Omni
OneBeacon
Orion Auto
Pacific Specialty Insurance Co
Peachtree Casualty Ins Co
Peerless Insurance
PEMCO Insurance Companies
Penn National Insurance
Permanent General Insurance Group
Personable Insurance
Preferred Mutual Ins Co
Progressive Insurance Group
Quality Casualty Insurance
Republic Group
Rockingham Group
SAFECO Insurance Companies
Safeway Insurance Group
Sagamore
Seibels Bruce Group
Selective Insurance Group
Sentry Insurance Group
Southern General Group
Southern Trust Insurance Co
Southern United Fire Insurance
Star Casualty
State Auto Insurance Companies
Stonewood
Strickland Insurance
Titan
Tower Insurance Co of New York
Travelers P&C
Trexis
Trexis One
United Automobile Ins Group
Unitrin Inc
Universal Insurance
Universal North America
Universal Property & Casualty Ins
Utica First
Utica National Insurance Group
Victoria
West Virginia Nat Auto Ins Co
Western Reserve Group
Westfield Group
Workmens Auto Insurance Co
Zurich/Farmers Group
Other (Not Listed)
Select
Boat
Commercial GL
Commercial Property
Commercial Vehicle
Farm
Homeowner
Life & Health
Mobile Home
Motorcycle
Personal Auto
RV & Travel Trailer
Umbrella
Work Comp
Add Company
Step 5 Review
Agency Information
Business Name
Business Owner Name
Business Owner Date of Birth
Business Legal Entity Type
Business Tax ID
Street Address
County
Business Mailing Address
Phone
Fax
Email
Website
Year Business was Formed
Producer Information
Producer
Born:
Alternate Producer
Born:
E&O Information
Errors and Omissions Carrier
E&O Policy Number
E&O Policy Effective Date
E&O Policy Expiration Date
Limit of Liability - Each Claim
Limit of Liability - Aggregate
Deductible - Each Claim
Deductible - Aggregate
Business Information
Years of Insurance Experience?
Is your agency a member of a Group or Aggregator?
Does your agency currently write business with National General through a broker?
Which National General Product are you most interested in writing?
Comparative Rater
Agency Management System
Companies Represented
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