Agent Appointment Application Lenox - MGA Commercial Truck Insurance

Section 1 – Agency Information

Agency Name(Required)

Agency DBA Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Agency Phone Number(Required)

Agency License Number(Required)

Agency NPN Number(Required)

Section 2 – Principal Agent Information

Principal Agent Full Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email Address(Required)

Individual Insurance License Number(Required)

NPN Number(Required)

Section 3 – E&O Insurance

E&O Insurance Company(Required)

E&O Policy Number(Required)

E&O Policy Limits(Required)

E&O Effective Date(Required)

E&O Expiration Date(Required)

Section 4 – Banking Information

For security, I recommend not asking agents to type full bank account and routing numbers into the Form. Instead, request secure supporting documentation.

Bank Name(Required)

Name on Account(Required)

Account Type

Are the Premium and Commission accounts the same?

Section 5 - Certification Statement:

I certify that the information provided in this application is true and accurate. I authorize Lenox General Agency, LLC to use this information and the documents provided for agency and/or producer appointment purposes.

Consent(Required)

I Agree(Required)

Name of Person Completing Application(Required)

Title(Required)

Date(Required)

Agent Appointment Application

Section 1 – Agency Information

Section 2 – Principal Agent Information

Section 3 – E&O Insurance

Section 4 – Banking Information

Section 5 - Certification Statement:

Company

Coverages

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