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NEW AGE UNDERWRITERS AGENCY, INC.
NEW AGE INSURANCE SERVICES, INC.
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Thank you for your interest in placing business with our company. Kindly fill out the following:
Legal Agency Name
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DBA
Street Address
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Street Address Line 2
City
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State
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Postal / Zip code
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Primary Email
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Secondary Email (commercial/personal agent, employees) [N/A if not applicable]
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Website
Phone
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EXT#
Years in Business
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Total Agency Volume
Percentage of Business
Number of Office Locations
Number of Employees
States Licensed
Agent NPN # [https://nipr.com/help/look-up-your-npn]
Niche Target/Market's?
Top 5 Direct Carriers
Affiliated with any other Aggregator or Cluster group?
Interested in our Aggregator Programs? (Quote, Bind and Issue Programs)
Attune
Blitz
Coterie
Foxquilt
Next
Pathpoint
Simply Business
Steadily
Victor
E&O Expiration Date
*
E&O Dec page or COI
*
Upload PDF File/Max 3mb.
Must show carrier, coverage dates, limit of liability and deductible. A minimum limit of $1,000,000
Agent License
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Please attach a copy of the current Broker's License.
Agency License
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W9
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Please attach a copy of current W-9.
Additional Documents
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to view & download the Brokerage Agreement
E-Signed Brokerage Agreement
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Name
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Title
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Your Signature
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Signature Date
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