Appointment Application for Personal Auto and Renters Coverage

General Information:

*required information

Agency Name *

Mailing Address *

Mailing Address

Address

Address 2

City

State

Zip/Postal

Agency is *

Individual

Corporation

Partnership

Other

Please describe

Physical Address

Address

Address 2

City

State

Zip/Postal

Additional Locations *

If Yes, how many locations?

Agency Phone *

Agency Fax

Agency Email *

Agency Website

Authorized Contract Signer Information

Signer Name *

Signer Title *

Agency License # *

Primary State Licensed In *

Agency Personnel

Principal - Name *

Title *

% of Ownership *

P&C License # *

Attach a copy of the P&C License when you submit.

Professional Designations

Agency Automation

Comparative Rater *

Section

Additional Principals - Name

Title

% of Ownership

P&C License #

Attach a copy of the P&C License when you submit.

Professional Designations

Add More Principals Remove

Management System *

Agency Experience

Top 3 Auto Carriers

Auto Carrier 1 *

WP: $ *

LR: *

Auto Carrier 2 *

WP: $ *

LR: *

Auto Carrier 3 *

WP: $ *

LR: *

Background Information

On the following questions, any "Yes" answer requires a separate statement, including dates, location, basis of charge, and legal documentation indicating disposition of case.

Has any license applied or issued to you by any public authority ever been denied, suspended, or revoked, including any license for which you were authorized to act? *

Yes

Have any agency contracts ever been cancelled for cause? *

Yes

Are you indebted, other than current accounts, to any insurer or person for unpaid premiums or return on premiums? *

Yes

Has any insurance, title, or escrow license ever been refused, suspended, or revoked by any State? *

Yes

Have you ever been charged, arrested, or convicted of a felony? *

Yes

Have you ever been charged, arrested, or convicted of a misdemeanor other than minor traffic violations? *

Yes

Have you ever received an Executive Pardon? *

Yes

Have you ever been permitted to change plea of guilty after conviction or had a verdict vacated? *

Yes

Have you ever filed bankruptcy, been sued, or had a judgment entered against you? *

Yes

Have you ever pleaded nolo contendere to any charges? *

Yes

Has any bond been canceled for cause? *

Yes

Have you ever been refused a bond by any company? *

Yes

Additional Branch Locations

Please include information for all locations you would like included with your appointment.

Section

Branch Name

Mailing Address

Address

Address 2

City

State

Zip/Postal

Physical Address

Address

Address 2

City

State

Zip/Postal

Branch Contact

Branch Email

Agency Phone

Agency Fax

Add More Locations Remove

Attachments

E&O (Minimum $500,000) *

Maximum file size: 2.1MB

All Agency and Producer Licenses *

Maximum file size: 2.1MB

Attach Additional Files

Maximum file size: 2.1MB

Submit Application

I hereby certify under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge and belief. I also hereby agree to the disclosure and release of any information pertinent to this application held by any person or any educational, law enforcement, governmental or business entity.

Signature *

Please enter a valid US cell phone number to complete the Appointment Application form. Text verification is required to enable the Submit button below.

Cell Phone *

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Link to our privacy policy.

Signed Name *

Date *

Confirmation Email *

Enter Email

Confirm Confirmation Email *

Confirm Email

OTP

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How did you hear about Hallmark? *

If you have questions, please contact our Internal Marketing Department at (800) 486-5616, extensions 5831; or email us at marketing@hallmarkinsco.com.

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Appointment Application for Personal Auto and Renters Coverage

General Information:

Authorized Contract Signer Information

Agency Personnel

Agency Automation

Section

Agency Experience

Background Information

Additional Branch Locations

Section

Attachments

Submit Application

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