Become an E-Risk appointed wholesaler

Interested in becoming an appointed E-Risk broker? Please fill out the form below. If you are a retail agent, please contact your preferred wholesaler for any questions or concerns regarding E-Risk.

General Producer Information:

*indicates a required field

You need to be a wholesale broker to apply for appointment, please confirm. *

Yes, I am a wholesale broker

Contact Name *

Company Name *

Street Address *

City *

State *

Zip *

Website *

Email Address *

Phone number *

Date Established

Complete the following questions:

1. Briefly describe the type of insurance your company specializes in handling:

2. List the major Insurance companies you represent and your premium volume:
Company

Volume

Company

Volume

Company

Volume

3. Projected Premium volume to E-Risk in the next three years:

1st Year:

2nd Year:

3rd Year:

4. Has a Principal or Officer of your office ever been charged or convicted of fraud or felony? *

Yes

5. Has your insurance license ever been suspended and/or revoked, or have you ever been fined by an insurance department? *

Yes

ESI05424

EMAIL ID: ESI05424