Wholesale Brokerage Insurance Company

Agency Inquiry

Thank you for your interest in our agency! To become an appointed agent/broker please complete the following application for Producer below.

Please Note: Completing this form does not automatically approve your agency application. After consideration and review of your submission, one of our representatives will contact you with any questions and to set-up an appointment.

* Name of Agency

* Contact Person

* Agency Address

* City

* State

* Zip Code

* Telephone Number

Fax Number

* Email Address

Year Established

* Type of Ownership
Please Select

DBA (if applicable)

* Primary Banking Facility

Agency Website Address (if applicable):

* E&O Carrier / Limit / Expiration

Companies Represented / Year Signed

* Has your License ever been suspended, revoked or cancelled ?
(If yes, please explain below:)

* Has any person or organization filed any formal complaint with The Commissioner of Insurance against you or anyone in your organization?
(If yes, please explain below:)

I/We hereby certify that everything stated in this form is true and correct. Commonwealth Insurance Partners LLC is authorized to check my history. I/We agree to be personally liable to Commonwealth Insurance Partners LLC for all premiums collected on the firms' behalf for all new and renewal business produced on an account. No binding authority is granted. Each Producer owns and controls the use of the expiration, however; the use and control of expirations shall be vested in Commonwealth Insurance Partners LLC as additional security for the payment of the premiums should the Producer default on payment or agency billed items.

* Please provide your initials here that you agree to the above:

You will also be required to provide Commonwealth Insurance Partners LLC with a copy of your Agent/Individual Brokers License and a copy of the Agency's E&O Policy.

Insurance Tools and Resources

At Commonwealth Insurance Partners, LLC we have assembled a number of insurance-related tools & resources for the use of our clients. For additional information or clarification, please speak with a member of our team. Our knowledgeable staff will be happy to assist with any inquiries you may have.

Browse Insurance Resources

Insurance Forms Library

We have compiled a library of the most useful insurance forms for you to easily download. These documents have been added for your convenience and may be viewed, downloaded and printed at any time.
All documents are in pdf file format.

Browse Insurance Forms