Broker Application

GENERAL INFORMATION

All Fields Required
Name of Agency *

Mailing address *

Street address (if different)

City, State Zip *
,  
County *


Phone # *

Fax # *

Tax ID # *


Corporation
LLC
Partnership
Sole Proprietor

Volume of business brokeraged to wholesalers *
$ P&C
$ Auto

Products you wish to access
 Transportation
 Property
 General Liability
 Workers Compensation
 Umbrella
 Small Business Unit (SBU)
How Did You Hear About Us?



CONTACT INFORMATION

Agency Principal *

E-mail Address *


Transportation Contact *

E-mail Address *


P & C Contact *

E-mail Address *


Accounting Contact *

E-mail Address *



LICENSING INFORMATION - COMPLETE ALL THAT APPLY *

 PA Producer Licensee
Name of Licensee 
 PA Non Resident Licensee
Name of Licensee 
 DE Producer Licensee
Name of Licensee 
 DE Non Resident Licensee
Name of Licensee 
 IN Producer Licensee
Name of Licensee 
 IN Non Resident Licensee
Name of Licensee 
 KY Producer Licensee
Name of Licensee 
 KY Non Resident Licensee
Name of Licensee 
 MD Producer Licensee
Name of Licensee 
 MD Non Resident Licensee
Name of Licensee 
 DC Producer Licensee
Name of Licensee 
 DC Non Resident Licensee
Name of Licensee 
 MI Producer Licensee
Name of Licensee 
 MI Non Resident Licensee
Name of Licensee 
 NC Producer Licensee
Name of Licensee 
 NC Producer Licensee
Name of Licensee 
 NJ Producer Licensee
Name of Licensee 
 NJ Non Resident Licensee
Name of Licensee 
 OH Producer Licensee
Name of Licensee 
 OH Non Resident Licensee
Name of Licensee 
 VA Producer Licensee
Name of Licensee 
 VA Non Resident Licensee
Name of Licensee 
 WV Producer Licensee
Name of Licensee 
 WV Non Resident Licensee
Name of Licensee 

THE FOLLOWING DOCUMENTS ARE REQUIRED IF APPROVED

1. A copy of your E & O Declarations page
2. A copy of all licenses checked above (agency and individual licenses are required)
3. A signed brokerage agreement (will be provided upon approval)

        

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Interstate Insurance Management is a series of RSG Underwriting Managers, LLC. RSG Underwriting Managers is a Delaware Series limited
liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Insurance Services, LLC License # 0E50879
Website Designed and Developed by Smartsite by Inspotlight