Bankers Insurance Group Agent Signup

Please complete our online questionnaire. Your information will be forwarded to our Territory Sales Manager for further consideration. Due to the volume of requests received, please allow 2 weeks for a response. Thank you for considering Bankers Insurance Group as a carrier partner.

All fields are required unless otherwise noted.

Contact Information

Agency Legal Name

Agency DBA Name (optional)

Contact Department

Contact Title

Physical Address

Mailing Address

Copy Physical Address to Mailing

Agency Information

Federal Tax ID#

Business Type

Principal First Name

Principal Last Name

Principal Email

Principal Phone

Interested in a Bankers contract for:
(hold Ctrl or command key to select more than one option)



Additional Agency Information

Years in Business

Have there been changes in Ownership?

If Yes, When (Year)?

Prior Agency Name?

Number of Licensed L&H Producers

Number of Licensed P&C Producers

Number of Personal Lines CSRs

Number of Commercial Lines CSRs

Has Agency Ever Represented Bankers?

If Yes, Provide Producer Code

Overall Premium Size of Agency

Any account current or unearned commission balances past due to any company?

Any judgements or suits against Agency?

Has any carrier terminated the Agency in the past 3 years for production and/or adverse loss ratio?

Have you or anyone in your Agency ever been convicted of a felony crime in any state or federal court?

Any license suspensions in the past 5 years?

Any other business (e.g. real estate) conducted from premises?

Is the agency affiliated with a national or regional brokerage firm?

Please explain any "YES" answers from the above questions.

Agency Affiliation

Citizens Agency ID (Leave blank if n/a)

Citizens Agent ID (Leave blank if n/a)

PIA Member?

IIAA Member?

LAAIA Member?

FAIA Member?

List any other organizations (optional)

Agency Book Information

Personal Lines Volume

Commercial Lines Volume

Carrier #1

Premium Volume #1

Carrier #2

Premium Volume #2

Carrier #3

Premium Volume #3

Flood Book Information

Flood Lines Volume

Flood Partner #1 (optional)

Estimated Premium #1 (optional)

Flood Partner #2 (optional)

Estimated Premium #2 (optional)

Flood Partner #3 (optional)

Estimated Premium #3 (optional)