Agency Profile

Become a JM Wilson Agent

To become a JM Wilson agent, complete our agency profile form below. Once your profile is received, a JM Wilson team member will be in touch to continue with the appointment process. Have questions before you get started? Contact the Agency Relations Specialist in your state.

PLEASE NOTE – the following items are required in order to successfully complete the appointment application form below:

• Current E&O policy information
• Current W9 form completed/signed
• Consent to run credit report

Agency Name (as shown on Agency License): *

DBA:

Agency Primary Email: *

Agency Primary Phone: *

Agency Fax:

Agency Website:

Completed W9: Only a PDF file under 10.00MB is accepted. If needed, download a new W9 form from the IRS.

Years in Business: *

Agency Type: * Please select: Corporation LLC Partnership Sole Proprietorship

Agency’s Primary Physical Address:

Address: *

City: *

State: * State: Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP: *

Does the agency have additional locations? *

Yes

No

The mailing address is the same as the physical address.

Mailing Address:

Mailing Address: *

City: *

State: * State: Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP: *

States Licensed In:

State(s) in which your agency is licensed to write: * All States Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Ownership

Please ensure ownership percentages total 100%.

Owner

Owner Job Title: *

Owner Legal Name: *

Owner DOB: *

Owner Email: *

Percent Ownership: *

Home Address: *

Home City: *

Home State: * State: Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Home ZIP: *

add additional owner

Key Contacts:

Receive Policies and Endorsements

Job Title: *

Full Name: *

Email: *

Phone: *

Extension:

Receive Statements and Billing Communications

Job Title: *

Full Name: *

Email: *

Phone: *

Extension:

Main Contact for Questions/Updates

Job Title: *

Full Name: *

Email: *

Phone: *

Extension:

Additional Contacts:

Contact

Job Title:

Full Name:

Email:

Phone:

Extension:

add additional contact

Premium Volumes

Agency Premium Volume: * Please select: Under 1 Million 1-5 Million 6-10 Million Over 10 Million

Personal Lines Percentage: *

Commercial Lines Percentage: *

Please list Wholesalers/MGAs you placed business with last year:

Wholesaler/MGA

Name: *

Types of Business Placed: *

add additional Wholesalers/MGAs

How did you learn about JM Wilson? *

Internet

Social Media

Worked with JM Wilson previously

Referred by an agent or company

Advertisement/Promotion

Other

Can you please explain to us a little more about how you heard about us? (i.e. name of the person, site, agency, etc.) *

Are you a part of an agency network or cluster group? *

Yes

No

If yes, what is the name of the agency network or cluster group?

Have you spoken with a JM Wilson Underwriter? *

Yes

No

If Yes, whom did you speak to? Please enter their name if you know it:

What lines or classes of business will you be looking to JM Wilson for? Select all that apply. *

Brokerage

Marine

Personal Lines

Property & Casualty

Surety

Trucking

Would you like to receive a premium finance proposal with qualifying quotes? *

Yes

Maybe

No

Errors and Omissions Insurance

Company: *

Policy Number: *

Expiration Date: *

Liability Amount: *

Deductible: *

The above information is true to the best of my knowledge. I authorize JM Wilson to make whatever inquiries they deem necessary to approve this application for appointment to do business with them. Investigation will include a credit report.

My Title: *

My Full Name: *

My Email: *

A copy of all the information you submitted will be emailed to you.

I grant approval and authorization to JM Wilson to run a credit report on any/all agency owners.

Yes, I agree to share my information with JM Wilson and receive communication including email. By agreeing, I confirm that I agree to the handling and processing of my data as described in our privacy policy.

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