NOTE: Agents may only sell in the state(s) in which they are licensed.

Producer Information

Please Complete the following in regards to the producer information.

  • select
  • select

Contact Information

Please Complete the following about the contact for this producer.


Billing Contact Information

Billing Contact Address

 Check if address is same as above, if different please complete:

  •  
  • select

Documentation Section

Please Upload Files (e.g. PDF, GIF, JPG etc.) containing the following documents: Your Agency and/or producer license(s); E&O policy declaration; and a completed W9. if you prefer to email or fax us your documentation, you may fax us at 773-897-5381 or email at NewProducerSignup@global-indemnity.com, please include a license for each state in which you are licensed to sell.

Please attach commercial property license
Please attach current E&O declaration page
W9 Template
Must be signed AND dated within the last two years
Only select one option for the entity type in Box 3
Line 1 (Name) must be completed
select
Check if you are licensed in multiple states
 

* denotes a required field.