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.

Contact Information

* required information
Agency Name*    
Address 1*    
Address 2    
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
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
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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    • Dawn Novelli featured in recent talk!

      We would like to share something that brought a smile to our faces. We have a broker, Joseph Stringer from Anderson Insurance, who was a guest speaker at a business forum discussing the power of vocation. Early in his speech, and immediately following his praise for Martin Luther King, Jr. he mentions our own Dawn Novelli. Highlighting for the group just how important her role is and how well she performs in that position. Please take a moment to listen to the audio file snippet attached.

      listen here
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