Step 1: General Agency Information
Agency DBA
Legal Name
Phone Number
Cell Number
Fax Number
Website
Physical Address
Address 1
Address 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Plus 4
Is your Mailing Address the same as your Physical Address?
Yes
No
Mailing Address
Address 1
Address 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Plus 4
Is your Billing Address the same as your Physical Address?
Yes
No
Billing Address
Address 1
Address 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Plus 4
Do you have additional locations other than the ones listed above?
Yes
No
Additional Locations Address
Location Name
Address 1
Address 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Plus 4
Organization Type
Please select...
Corporation
Individual
LLC
Partnership
Federal Tax ID
Format of Tax ID is XX-XXXXXXX
Agency Licenses
Agency License #
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Other
NPN #
E&O Carrier Name
(min limits of $1,000,000)
E&O Policy Number
E&O Expiration Date
No. of Employees
Agency Mgmt System
Please select...
AMS
Applied
Other
Step 2: Agency Principals, Officers, Contacts
Agency Principal Information
First Name
Last Name
Direct Phone
Email Address:
License Information
License Number
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Other
Home Address
Address 1
Address 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
plus 4
Birthdate
Social Security Number
Primary Contact?
Yes
No
Agency Primary Contact Information
First Name
Last Name
Department(s)
Accounting
Claims
Commercial Lines
Commercial P&C
Commercial Transportation
Financing
Marketing
Personal Auto
Personal Lines
Personal Property
Sales
Other
Other Department
Direct Phone
Email Address:
Do you have other contacts to add?
Yes
No
Other Contact Information
First Name
Last Name
Department(s)
Accounting
Claims
Commercial Lines
Commercial P&C
Commercial Transportation
Financing
Marketing
Personal Auto
Personal Lines
Personal Property
Sales
Other
Other Department
Direct Phone
Email Address:
E-Policy Delivery and Accounting Statement Delivery Information
E-POLICY DELIVERY
SIU's Electronic Policy Delivery System is designed for the Independent Agency to received documents via email in a PDF format. View, save, print and email Personal, Commercial Property & Casualty and Commercial Transportation documents, in lieu of receiving a paper version. Included in the e-Policy Delivery are the Agent and Insured copies of Policies (New and Renewal) and Endorsements.
By default all policy correspondence will be sent to the email address provided for the agency principal. If you would like to add a second email address to receive policy correspondence or would like to edit the information we have on file please complete the section below:
Primary Policy Delivery Email Address:
Secondary Policy Delivery Email Address:
ACCOUNTING STATEMENT DELIVERY
SIU Accounting is now paperless! Statements are available on the first business day of every month online at www.siuins.com.
By default all accounting correspondence will be sent to the email address we have on file for the agency principal. If you would like to add a second email address to receive accounting correspondence or would like to edit the information we have on file, please complete the section below.
Primary Accounting Delivery Email Address:
Secondary Accounting Delivery Email Address:
Step 3 : Market & Premium Information
This information will be used to develop a personalized communications plan to ensure timely notification
of relevant product information.
Total Written Premium
(total written premium to include auto, personal lines, and commercial)
Premium Range
Please select...
Up to 1 million
1-3 million
3-5 million
5-10 million
10-20 million
20-30 million
over 30 million
E&S Premium and Markets Information
Total E&S Premium
%
Please list all of your contracted E&S markets:
Why do you want to be an SIU producer?
What are you interested in writing with SIU?
(indicate both current interest or potential)
Personal Auto
Yes
No
Other Personal Lines
Yes
No
Commercial Lines
Yes
No
Commercial Transportation
Yes
No
Professional Lines
Yes
No
Premium Finance
Yes
No
Indicate your premium percentage breakdown
(total percentage should be 100%)
Personal Auto
%
Other Personal Lines
%
Commercial Lines
%
Commercial Transportation
%
Professional Lines
%
Total Percentage
%
Banking
With whom do you finance your E&S book?
Step 4 : Documentation Attachments
Please attach all documents requested below in a PDF or Word formats.
In Force E&O
Declaration:
Agent License:
Agency License:
W-9:
FL 220
Click here to download blank FL 220 form
GA COA (Only complete Section 3)
Click here to download blank GA COA form
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Contact Information
