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Agency Application

Agent Contact Information
Name:       Phone: 
Email: 
General Information
Agency Name:       Entity Type: 
Address: 
City:    FEIN/SSN: 
State:    Phone: 
Zip:    Fax: 
Website:    # of agents: 
Agency Administrator
Please identify whom you would like to appoint as the administrator for your agency? This person will maintain agency authorized user's access, train new agency authorized users, dispense Midwest document downloads to appropriate agency personnel, receive cancellation notifications and have the ability to see all submissions.
Name: 
Email: 
Principals
Include each Name and Percentage of Ownership.
Name Ownership %
Satellite Offices
Does your agency have satellite offices?: 
If so, are these offices under your direct control?: 
List all locations: 
Market Information
What is your agency's total workers' compensation volume? Please include both mono-line workers' compensation carriers and multi-line carriers.
Premium Volume?: 
Policy Count?: 
Please List Total Workers' Compensation Volume by Carrier:

Carrier Premium Volume Policy Count Loss Ratio
Please enter your premium volume and policy count below $10,000 EAP
Premium Volume?: 
Policy Count?: 
Please enter your premium volume and policy count above $100,000 EAP
Premium Volume?: 
Policy Count?: 
Does your agency broker Workers' Compensation coverage for other agencies?: 
Disclosures
Do all agents selling and marketing business for the agency have a current producer's license?: 
Has your agency ever been the subject of a bankruptcy, receivership or similar proceeding?: 
If so, provide explanation: 
Has any owner, officer, director, partner, employee or solicitor of the agency ever been the subject of a disciplinary action by any insurance authority?: 
If so, provide explanation: 
Has there been an errors and omissions claim made against the agency or any of its employees, principals, (past or present), within the last 5 years?: 
If so, provide explanation: 
Bank Reference Information
Name:    Phone: 
Address: 
Midwest utilizes and requires electronic commission payments. The "authorization form for electronic commission payments" will be included with the contact packet.

 



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