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Antai Producer Registration form
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* Indicates required question
Email
*
Your email
In order to be appointed with Antai Financial Center, you must be a licensed Broker/Agent and carry Errors & Omissions coverage.
Are you registering for as an individual or as a group?
*
Group
Individual
Agent Name
*
Your answer
Agency DBA
*
Your answer
Agency Corporation Name
*
Your answer
Legal Entity
*
Individual
Partnership
LLC
Corporation
Street address
*
Your answer
Mailing address (if different)
Your answer
Phone
*
Your answer
Fax
Your answer
Last 4 digit of SSN (if individual) or Federal Employer ID (if group)
*
Your answer
License Number
*
Your answer
License Expiration Date
*
MM
/
DD
/
YYYY
E&O Coverage Carrier
*
Your answer
E&O Coverage Policy Number
*
Your answer
E&O Coverage Expiration Date
*
MM
/
DD
/
YYYY
Corporate officers Names
Your answer
Producers Names (if filing for group)
Your answer
Insurance Companies You Represent
*
Your answer
MGA/Surplus Lines Brokers you do business with
*
Your answer
Your name
*
Your answer
Your title
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
Submit
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