Agency Appointment

Please fill this form out as completely as possible. This information will be used to populate our Agency Qualification Form only. After clicking submit, the form will be sent to Mendota's Business Development Manager for review and follow up. Fields marked in blue are required.

For which state are you requesting an Agent / Broker appointment?

Agency Name

Business Address

City

County State Zip

Mailing Address
(if different)

City

County State Zip

Phone Number

Fax Number

Primary Email

Website Address

DOI License
Number

Year Agency Established

Taxpayer Id
Status

IndividualSole ProprietorPartnershipCorporation

Legal Name

Tax ID / SSN

Principal(s) Name(s)

Key Contact person(s) responsible for placement of specialty personal lines risk

List at least two standard companies with which your agency does business.

What is you agency's total annual written premium?

Under $1 Million$1 to $3 Million$3 to $5 MillionOver $5 Million

What percentage of your agency volume is non-standard automobile?

0% to 25%26% to 50%51% to 75%76% to 100%

List your largest Auto Carriers:

	Company 1	Company 2	Company 3
Company Name
3 Yr. Loss Ratio
Written Premium

Projected first year written premium volume comitment with Mendota?

Security Check: Enter the code above.

If you have any questions, please click here to contact our Contracts / Licensing Department.

HOPSMAXWEBP2

version: 2.1.0.1258