Producer Enrollment
Organization
Legal Name of Organization
FEIN
Mailing Address
Address
City
State
-- choose a state --
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
ZIP
County
Country
Physical Address
Address
City
State
-- choose a state --
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
ZIP
County
Country
Contact Information
Web Address
Telephone Number
Fax Number
Email Address
Licensing
Are you operating as a DBA in any state(s)?
Yes
No
If "Yes," please provide the complete DBA
name and state where the DBA was registered.
Agency Type
(choose one)
Corporation
Partnership
Sole Proprietor
LLC
Entity License Number–Resident
Effective Date
Renewal Date
Entity National Producer Number (NPN)
Production States (check all that apply)
Check All
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Name of Brit Representative/Underwriting Contact
-- choose one --
Karen Accurso
Joe Almanzar
Diana Batista
Mark Blair
Gysel Blindauer
Elena Brandt
Christin Buono
Lisette Cart
Amanda Castro
Diane Cotrim
Steve Courchaine
Kristy Curtis
Alicia Dodson
Anthony Fiorenzi
William Frohne
Maryann Gandhi
Kirk Goeldner
Rich Hartman
Zachary Hicks
John Holohan
Kristen Hunter
Jim Kelly
Amanda Kohnen
Jon Liening
Melissa LoCoco
Courtney Lynn
Danielle Mack
Justin MaGee
Martin Manion
Christine Martin
Craig McGinnes
Craig McGinness
Mat McLaughlin
Matthew McLaughlin
Cheyne Meseroll
Noreen Metcalfe
Ryan Mimmo
Sean Neese
Richa Niblett
Jeff Norton
James Patterson
Austen Pearce
Austin Pearce
Rachel Perry
Nick Pozzebon
James Quinn
Marc Robinson
Douglas Ruhlman
Yasu Saegua
Yasu Saegusa
Julianne Shillington
Shara Smith
Kent Stepanishen
Lysa Taylor
Douglas Trainor
AJ Tyler
Alonzo Tyler
John Verderosa
Brian Whooley
Garick Zillgitt
Errors & Ommissions Insurance
Carrier
Limit: Occurrence
Aggregate
Deductible
Expiration Date
Please attach a copy of the declarations page of your
current agency E&O policy and a list of your principals/officers.
Please attach a copy of your latest financials.