Buckingham Badler Associates Inc. - General Insurance Agents

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Buckingham Badler Associates - General Insurance Agents

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Broker Application

Date:

Firm Name:

Address:

Telephone:

Fax:

Email:

Website:

Federal ID Number:

Social Security Number:

Owners Name:

Home Address:

Corporate Officers:

E & O Policy Carrier

E & O Policy Number

E & O Policy Expiration Date

Resident State License Number:
* copy of E&O DEC must be sent

Companies and agencies you currently have an account with: 1.
2.
3.
4.

Name of your Trust Depository:

Address of your Trust Depository:

Approx. Volume of Business:

% Personal:

% Commercial:

Agency Licenses, If any:

I am Licensed in the following states as a Non-Resident Broker:

In consideration for the issuance of a brokerage account, I agree that in the event the company, during the continuance of this account or after its termination, refunds premiums under any policy by reason of cancellation or otherwise, then I will return to the company the commission previously received by me on the amount of premiums so refunded, I will also guarantee all earned premiums on new business.

Yes:
* By checking "YES" you agree to the above.

Or you can print out this page and fax it to 347-252-5010

If there are any questions or concerns feel free to email us at info@bbainsurance.com