New Agent Profile Sign-Up

Please fill out the following form if you are wanting to contract with Graham-Rogers as an agent. We will contact you once we have completely reviewed your completed answers.

AGENT REGISTRATION FOR PORTAL ACCESS – CLICK HERE

Agency Is Owned By

Agency Name

Agency Contact Name

First Name

Last Name

Mailing Address

Apt, suite, etc.

Country

City

State

Zip code

Physical Location

Apt, suite, etc.

Country

City

State

Zip code

Agency Phone #

Agency Fax #

Agency Is......

How many employees? (including yourself)

Number of years in business under present name?

For the principal agent: How many years of experience (min. 2yrs required)

FEIN

During the past 5 years has the agency acquired, merged with another firm, or changed names?

Yes

Are there any other branch offices affiliated with the agency?

Branch Name

Street Address

State

Zip

Phone

Fax

Please describe how you heard about Graham-Rogers.

First Name

Last Name

Who is your Errors & Omissions Carrier?

Expiration Date of Agency E&O policy

Total Premium Volume

Total Premium Volume Last Year

Total Premium Volume Projected for the Current Year

Personal Lines

Commercial Lines

Which Lines of Business Are You Most Interested In?

Personal Lines

Specialty Lines

Commercial Auto

Please check all that apply

Company Name

Premium Volume

Loss Ratio

Has any company cancelled your agency contract in the last three years?

Yes

Has a license pertaining to any type of insurance related activity held by you or any employee of the agency or organization ever been revoked, suspended, or withdrawn by any regulatory authority?

Yes

reCAPTCHA is required.