Get Appointed with Nationwide®

Please, fill all the fields to continue.

Which lines of business are you interested in writing with Nationwide?

Personal Lines
Commercial Lines
Farm Lines

Have you been referred by a commercial submission platform system (i.e. Bold Penguin, Tarmika, etc.)?

Yes No

General Agency Information

Agency Name*

Address*

Address 2

City*

State*

Zip*

Agency Phone*

Email*

Agency Website*

Agency Fax

Principal Name*

Principal Contact Name (If Different from Principal)

Principal Email*

Sub Location Primary Contact Email (If Different from Principal)

Primary Contact Phone (If Different from Principal)

Do you have additional locations?

Is the Primary Contact Authorized to Sign Contracts?*

Yes No

What agency management system do you use?*

Do you use a comparative rater? If yes, which one? *

Has your agency ever applied for appointment, or been appointed by any of the Nationwide family of companies?

Yes No

If yes, when?

What year was your agency established?

What Nationwide products are you interested in selling?

Is your agency affiliated with one of the Insurance Journal top 100 Firms, a Network or an Aggregator?* Yes No

If yes, when?

Agency Production

What is your agency’s total written premium?*

% of premium for Personal Lines:*

% of premium for Commercial Lines:*

What is your agency’s Year-Over-Year written premium Growth?

What is your agency’s 3 Year Total Loss Ratio?

Please list your top 3 Personal Lines Carriers by total written premium:

Personal Lines Carrier Top 1*

Personal Lines Carrier Top 1 Written Premium $

Personal Lines Carrier Top 2*

Personal Lines Carrier Top 2 Written Premium $

Personal Lines Carrier Top 3

Personal Lines Carrier Top 3 Written Premium $

Please list your top 3 Commercial Lines Carriers by total written premium:

Commercial Lines Carrier Top 1*

Commercial Lines Carrier Top 1 Written Premium $

Commercial Lines Carrier Top 2*

Commercial Lines Carrier Top 2 Written Premium $

Commercial Lines Carrier Top 3

Commercial Lines Carrier Top 3 Written Premium $

New monthly quote flow volume:*

Issue rate:*

What are your top 3 industries that you prospect/target and the total written premium associated with each industry?

Top 1 industry

Top 1 industry total written premium $

Top 2 industry

Top 2 industry total written premium $

Top 3 industry

Top 3 industry total written premium $

How much farm do you write today?

What carriers do you write Farm with today?

Employee Information

Number of all licensed employees (e.g., producers, account executives, and CSRs)*

Do you conduct background checks on your employees?

Yes No

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