Become an agent or broker with H.T. Bailey Insurance Group. If you
are looking for a wholesale broker that is committed to providing
professional, personalized specialty insurance, you've found it
here!
Join the growing list of agents and brokers already part of the H.T.
Bailey family!
To become
a agent, please complete the
following form below. After an agency representative has
contacted you, you may be asked to submit to H.T. Bailey current
copies of your E&O Dec Page and insurance agency license as well
as copies of licenses for those authorized to transact business
under the agency license.
*
Indicates a required field
*Contact
Person
*Mailing
Address
*City
*State
*Zip
Code
*Telephone
Number
Fax
Number
*Email
Address
How
long in business?
Type
of Ownership
List the
name(s) of the owner(s) of the agency.
1.
*Owner's
Full Name
2.
Owner's Full Name
Birthdate
Birthdate
Key Agency
Personnel
1.
Full
Name
Title/Position
2.
Full
Name
Title/Position
3.
Full
Name
Title/Position
Annual
Premium Volume
*Total
Volume All Lines
$
Do you
maintain E&O Insurance? *
Has any
company cancelled or refused to renew your E&O policy?
If
yes, why?
Has any
company withdrawn from your agency in the past three
years?
If yes, give
name of company and reason.
I/You hereby certify that everything stated in this form
is true and correct. H.T. Bailey Insurance Group
is authorized to perform a complete background check and
history of your agency.
* Please provide your initials here if you agree to the
above:
Press the
Submit button above only once! - Wait for your
information to be sent to our office. This can take less
than 30 seconds and you will receive a confirmation page when
it has been transferred. Thank You.
