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Agent Application

Our products offer security, and our services deliver peace of mind. Insurance is easy with Wellington.

 
General Information

Agency Principals:

  Name % Ownership SSN / Tax ID Birthdate
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Agency Profile

Carriers you are currently pursuing appointments with

Carriers you are currently de-emphasizing

Production

Percentage of total agency volume

Current carriers utilized for new residential property business

  Carrier Last Year Volume ($) Last Year Loss Ratio (%) Est. New Monthly Applications
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Products of Interest
Miscellaneous
Comments

The maker of the foregoing application hereby authorizes Wellington Risk Insurance Agency, Inc. to confirm items comprising this application and to conduct or order any investigation deemed necessary to establish qualifications. The Undersigned hereby certifies that all information provided is current and factual to the best of his or her knowledge. Electronic Signature Disclosure

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