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Thank you for showing interest in ICW Group!
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Please select the coverage you are interested in.
Workers' Compensation
Catastrophe
General Information
First Name
*
Last Name
*
Email
*
Phone
*
Agency or Brokerage Name
*
Title
*
Physical State
*
Select a State
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Alaska
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*
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Alabama
Alaska
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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Work Comp
Your Total Inforce Work Comp Premium
*
Select from the options below
Less than $1 million
$1 million to $5 million
More than $5 million
Your Total Inforce Work Comp Policies
*
Select from the options below
1 to 10
11 to 25
More than 25
Agency Type
Agency Website
Is your agency currently appointed with our Workers Compensation division?
Yes
No
Catastrophe Insurance for Wholesale Brokers
This application is for a brokerage contract with Risk Insurance Brokers (RIB), the exclusive Underwriting Agent for Property Catastrophe Insurance with ICW Group. RIB is currently only accepting applications from wholesale producers holding a valid surplus lines license.
Operating Name or DBA
*
Exact Name on License
*
License Number
*
Email
*
Phone Number
*
States Licensed
Select your non-resident license states
State
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Hidden
Untitled
Persons to Contact
Underwriting Contact Name
*
Claims Contact Name
*
Accounting Contact Name
*
Physical Address
Physical Address Line 1
*
Physical Address Line 2
City
*
State
*
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Mailing Address
Is your mailing address the same as your physical address?
*
Yes
No
Physical Address Line 1
*
Physical Address Line 2
City
*
State
*
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Insurance Carrier References
These may be Managers, Underwriters, or Marketing Personnel.
Reference #1
Company
*
Name of Reference
*
Position
*
Phone Number
*
Reference #2
Hidden
Company
Hidden
Name of Reference
Hidden
Position
Hidden
Phone Number
Reference #3
Hidden
Company
Hidden
Name of Reference
Hidden
Position
Hidden
Phone Number
Reference #4
Hidden
Company
Hidden
Name of Reference
Hidden
Position
Hidden
Phone Number
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Business
What is your business type?
*
Individual
Partnership
Corporation
Year Established
*
Number of Locations
*
Principals
Principal One Name
*
First
Last
Principal One Title
*
Is principal one active?
*
Yes
No
Principal Two Name
First
Last
Principal Two Title
Is principal two active?
Yes
No
Principal Three Name
First
Last
Principal Three Title
Is principal three active?
Yes
No
Principal Four Name
First
Last
Principal Four Title
Is principal four active?
Yes
No
Principal Five Name
First
Last
Principal Five Title
Is principal five active?
Yes
No
Primary Market Area
*
Accounting Method Used
*
Bank Reference
*
Total Personal Lines Premium
*
Total Commercial Volume
*
Commercial Package Volume
*
Number of Current Clients
*
What is your forecasted premium with RIB for the next 12 months?
*
What is your forecasted premium with RIB for the second 12 months?
*
Is there a particular market, product or service need that RIB can meet for your agency better than your current carrier(s)?
*
Current Carrier Information
Tell us about four of your current carriers.
Year for premium and loss ratio information
*
Select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
Company
*
Commercial premium for year
*
Commercial loss ratio for year
*
Personal premium for year
*
Personal loss ratio for year
*
Company
Commercial premium for year
Commercial loss ratio for year
Personal premium for year
Personal loss ratio for year
Company
Commercial premium for year
Commercial loss ratio for year
Personal premium for year
Personal loss ratio for year
Company
Commercial premium for year
Commercial loss ratio for year
Personal premium for year
Personal loss ratio for year
Were there any shock losses which affected the loss ratios shown above?
*
Yes
No
If yes, please explain:
Agency Information
If you are an agency, has your agency ever had a termination of appointment by an insurance carrier?
*
Yes
No
Has your agency/brokerage ever had an appointment with Risk Insurance Brokers or one of its subsidiary companies?
*
Yes
No
Has you agency/brokerage ever had your license suspended, revoked, or otherwise restricted by the Department of Insurance or ANY state?
*
Yes
No
Have any of the principals, partners, officers, directors, or employees in your agency/brokerage ever been convicted in any state, federal, commonwealth, or territorial jurisdiction of felony crimes involving dishonesty of breach of trust or any violation of Title 18 U.S.C 1033?
*
Yes
No
If yes, please explain:
Has your agency/brokerage filed for bankruptcy in the last 7 years?
*
Yes
No
If your application is accepted, we will contact you to request the following items: W-9, copy of surplus lines license, and a copy of your E&O declaration.
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