Please fill in the form and download the attachments below.
You will receive a confirmation email shortly after you click ‘submit.’
Please respond to that email with your filled in and completed Producer Agreement, W-9, Current E&O Coverage, and Active State P&C Brokers Licenses.
Please note: All paperwork must match the name on the W-9.
How would you like to be contacted?
New Hyde Park – (516) 488-4747 – 1985 Marcus Ave, New Hyde Park, NY 11042Manhattan – (212) 999-4744 – 450 7th Ave, New York, NY 10123New Jersey – (732) 726-1400 – 1261 Headquarters Plaza, West Tower, 6th Floor, Morristown, NJ 07960
Fax Number – (516) 453-0199