Appointment Application for Personal Auto and Renters Coverage

How did you hear about Hallmark? *

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?

No

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

No

Have any agency contracts ever been cancelled for cause? *

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Have you ever received an Executive Pardon? *

Yes

No

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

Yes

No

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

Yes

No

Have you ever pleaded nolo contendere to any charges? *

Yes

No

Has any bond been canceled for cause? *

Yes

No

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

Yes

No

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) *

Drop a file here or click to upload Choose File

Maximum upload size: 8.39MB

All Agency and Producer Licenses *

Drop a file here or click to upload Choose File

Maximum upload size: 8.39MB

Attach Additional Files

Drop a file here or click to upload Choose File

Maximum upload size: 8.39MB

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 *

Clear

Signed Name *

Date *

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

Uploading Files. Please Wait.

Submit Application