New Broker Application

New Broker Application

If you are not currently a Maritime Program Group agent and wish to be considered for an agency appointment, please complete the short New Broker Application below. A representative from MPG will contact you shortly after receipt of your application to discuss your request for an appointment.

If you require further assistance, please contact: Damon Pesce, VP Business Development, at 800.366.8086 x1658, or Bill Worden, Western Regional Manager, at 800.366.8086 x1878.

Contact Information

* required information
Agency Name*    
Address 1*    
Address 2    
City*    
State*    
Zip*    
Number of Office Locations      
Ownership Structure*    
Primary Contact Name*    
Primary Contact Role?*    
Primary Contact Phone*    
Primary Contact Email*    
Primary Fax Number      
Accounting Contact Name*    
Accounting Contact Phone*    
Accounting Contact Email*    
Marketing Manager Name      
Marketing Manager Phone      
Marketing Manager Email    
Website Address      

Tell us about your agency

What is the split between personal lines and commercial? 
Personal:    %
Commercial:    %
What is your agency's total P&C premium volume?   
How many employees in your agency?   
Is your agency:   

Tell us about your portfolio

Complete the grid below about your existing portfolio or select N/A where applicable:

  PremiumPrimary Carriers
Boats/Yachts
Marinas, Dealers, Yacht Clubs, Boats Builders, Artisans
Builder's Risks
Motor Truck Cargo
Other Inland Marine Risks
Charter and/or Passenger Vessles
Ocean Marine Risks,
i.e. Marine Contractors, Commercial Hull and P&I, Cargo
USL&H
Private Client Services (Personal lines for high net worth customers)
How did you learn about Maritime Program Group?*    
Has your agency or a principle of your agency ever been fined by a state agency for insurance fraud?*
   
States your agency is licensed in:
 



















































Additional Information:      
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