Become A Producer – XS Specialty LLC

Agency Name *

Legal Name (If Different)

Agency ID

Website

Email Address *

Alternate Email Address

Phone *

Fax *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (If Different Than Physical)

Address Line 1

Address Line 2

City

State

Zip Code

Accounting Address (If Different Than Physical)

Address Line 1

Address Line 2

City

State

Zip Code

Business Entity *

Corporation
Partnership
Individual
LLC

If LLC, Please Select Tax Classification

C Corporation
S Corporation
Partnership

List other agency office locations that you would like added to our database. Include address and primary contact at each office. Please note that each location will be assigned it's own agency code.

Primary Contact

Full Physical Address

Contact Information

Please List Company Contacts Including Principal, Accountant, Marketing Manager, and Producers

Title

Name *

Phone

Email *

Do you have a small accounts department? *

Yes
No

If Yes, Size of Accounts Sent to Department and List Department Contact *

Premium Information

Agency Total Premium *

Agency Total Commercial Premium *

Total Placed with Wholesalers/MGAs *

Please indicate how much total premium your agency writes in each of these classes of business:

Coastal Property

Transportation

Other (Please Specify)

General Liability

Excess / Umbrella

Construction

Other (Please Specify)

D&O

E&O

Healthcare

Other (Please Specify)

Market Information

Please list the wholesale brokers or MGAs used by your agency below:

Broker / MGA Name

Annual Premium Placed

Classes Written

Additional Documentation

Please Upload the Following Files:

Click or drag a file to this area to upload.

1) Signed Producer Agreement

2) W-9

3) Copy of E&O Declaration Page

4) Copy of Licenses

Prepared By *

Date *

Producer Profile

Contact Information

Premium Information

Market Information

Additional Documentation

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