Broker Application

General Information






Volume of business brokered to wholesalers
Products you wish to access






Currently Contracted With Ryan Specialty Group

Contact Information

Name*
 Email*
  Professional Designations (If Any)
Agency Producers
Name
 Email
  Professional Designations (If Any)
 

Transportation Questionnaire

Business Volume
Which contracted insurance companies do you place these classes with
Identify wholesalers and MGAs you place these classes with
What companies do you access through these wholesalers/MGAs
Why do you need us
If we are able to meet your needs, approximately how much volume could be placed with our facility

Additional Documents

THE FOLLOWING DOCUMENTS ARE REQUIRED IF APPROVED

1. A copy of your E & O Declarations page
2. A completed and signed W-9
3. A signed brokerage agreement (will be provided upon approval)

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

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