Get appointed with Nationwide

Which lines of business are you interested in writing with Nationwide?

Personal Lines
Commercial Lines
Farm Lines

Have you been referred by a commercial submission platform system (i.e. Bold Penguin, Tarmika, etc.)?

Yes No

Is your agency affiliated with one of the Insurance Journal top 100 Firms, a Network or an Aggregator?*

Yes No

If yes, when?

General Agency Information

Agency Name*

Address*

Address 2

City*

State*

Zip*

Agency Phone*

Email*

Agency Website*

Agency Fax

Principal Name*

Principal Contact Name (If Different from Principal)

Principal Email*

Sub Location Primary Contact Email (If Different from Principal)

Primary Contact Phone (If Different from Principal)

Do you have additional locations?

Is the Primary Contact Authorized to Sign Contracts?*

Yes No

What agency management system do you use?*

Do you use a comparative rater? If yes, which one? *

Has your agency ever applied for appointment, or been appointed by any of the Nationwide family of companies?

Yes No

If yes, when?

What year was your agency established?

Agency Production

What is your agency’s total written premium?*

What is your agency’s Year-Over-Year written premium Growth?*

What is your agency’s 3 Year Total Loss Ratio?

New monthly quote flow volume:*

Issue rate:*

Employee Information

Number of all licensed employees (e.g., producers, account executives, and CSRs)*

Do you conduct background checks on your employees?

Yes No

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© 2024 Nationwide Mutual Insurance Company and affiliated companies, home office: One Nationwide Plaza, Columbus, OH 43215-2220. Nationwide Investment Services Corporation (NISC), member FINRA, Columbus, Ohio. In Michigan only, Nationwide Investment Svcs. Corporation.

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