Address:

155 Cranes Roost Blvd.
Suite 2020
Altamonte Springs, FL
32701

Toll-Free:

877-653-IPOA (4762)

Local:

407-260-8200

Fax:

321-281-4475

Contact Name:

Chris Hagle
marketing@ipoausa.com

Write More Business And
Increase Your Profits

Please complete the following form and we will begin the process of setting up an account for your agency. In addition, we will send you updates on new products, business-building tips and industry developments.

If you prefer, we would like to hear from you in person, so feel free to contact one of our offices below. We look forward to sharing our vision on how we can help you write more business and increase your profits.

NEW AGENCY REQUIREMENTS:
- Minimum of 2 years in business
- Minimum of $1,000,000 in current premium volume
- Minimum of $1,000,000 in errors & omissions coverage
- Minimum of 2 standard markets

THE FOLLOWING FORMS NEED TO BE COMPLETED IN ADDITION TO THE AGENCY QUESTIONNAIRE BELOW:
- Signed Brokerage agreement
- IRS W-9
- Copy of your agency license
- Copy of your E&O declarations page

Agency Questionnaire

*Required Fields.

Company Name*:

First Name*:

Last Name*:

Email*:

Web Site:

Address:

City:

State:

Zip:

Phone Number*:

Fax Number:

Years in Business:

Number of Employees:

Primary Contact:

Primary Email:

Agency Premium Volume:

Agency Specialties:

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