Start your Work Comp agent application We look forward to learning more about your agency. Please complete the form below to initiate the review process (or, you can use this PDF form and email to us).Your informationYour Name* First Last Title* Phone*MobileFaxEmail* IMPORTANT: You'll receive a copy at this emailAgency informationAgency Name* DBA Business Type* Broker Agency FEIN Federal Employer Identification Number. Must be exactly 9 digits with no dash or spaces and must not be all 9s or all 0s.Physical Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Mailing Address* Mailing Address is the same as Physical Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Workers' compensation marketWork Comp volume: $*Work Comp accounts*Number of accountsNumber below $25KNumber of producers*List the states you predominantly do business in.*Carrier informationPlease account for 90% of premium volume. Production reports are required prior to appointment.*CarrierPremium: $# of accounts5-year Loss Ratio Wholesale relationshipsList wholesalers used for workers' comp line and what ICW Group volume, if any, that you have with them.WholesalerCurrent volume $# of accounts Are you a member of a cluster (network of independent insurance agency partners)?* No Yes Please explainIs your agency affiliated with any other insurance carrier? (i.e. State Farm, Farmers)* No Yes Please explainBook of business profileDoes your agency specialize in a specific industry?* No Yes Please explainCompany informationHas your agency/brokerage ever had your license suspended, revoked, or otherwise restricted by the Department of Insurance of ANY state?* No Yes Please explainHas a carrier ever terminated your appointment?* No Yes Please explain when, why and which company(s)Has your agency/brokerage ever had an appointment with an ICW Group Insurance Company? (Ex. Insurance Company of the West, Explorer Insurance Company, VerTerra Insurance Company, or other subsidiary)* No Yes Please explainHave any of the principles, 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 or breach of trust, or any violation of Title 18 U.S.C. § 1033?* No Yes Please explainHas your agency/brokerage filed bankruptcy in the last 7 years?* No Yes Please explainPrincipalsCheck this box if you are a principal, to copy your information from above. Check this box if you are a principal, to copy your information from above. Principals*First NameLast NameTitlePhoneEmail Agency contract signatorWho at your company will be approving this appointment?Check this box if you are the approver, to copy your information from above. Check this box if you are the approver, to copy your information from above. Signator Name* First Last Title* Phone*Email* Who referred you? CaptchaNameThis field is for validation purposes and should be left unchanged. – Thank you for your interest in ICW Group! Notice of Collection of Personal Information
