JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Covercube Producer Application
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Agency Name
*
Your answer
Agency Phone
*
Your answer
Agency Address
*
Your answer
Agency Address 2
Your answer
Agency Email
*
Your answer
Agency License Number
*
Your answer
Year Established
*
Your answer
Ownership Type
*
Choose
Sole Proprietor
LLC
Corporartion
Partnership
Tax ID Number or Social Security Number (sole proprietor)
Your answer
Agency Annual Written Premium (all lines)
Your answer
Agency Annual Written Premium (auto)
Your answer
Comparative Rater
Choose
ITC/TurboRater (Zywave)
EZ Lynx
Quick Quote
Vertafore
PL Rater
None
Agency Management Software
Your answer
Agency Principal (Officer)
*
Your answer
Agency Principal
Your answer
Agency Principal 2 (Officer)
Your answer
Has any director, officer or owner of the agency been convicted of a felony, filed bankruptcy, or have any interruption in their agent license?
*
Yes
No
Required
Has the agency been terminated by a carrier or MGA or had any disciplinary action taken by any state or federal regulators?
*
Yes
No
Required
Has Agency maintained Errors & Ommission coverage for the last three years?
Yes
No
Producer Name / License Number
*
Your answer
Producer 2 Name / License Number
Your answer
Producer 3 Name / License Number
Your answer
Has any producer of the agency been convicted of a felony, filed bankruptcy, or have any interruption in their agent license?
*
Yes
No
Has any producer been terminated by a carrier?
*
Yes
No
Who is your largest auto carrier? What is your annual premium with them?
*
Your answer
Who is your second largest auto carrier? What is your annual premium with them?
Your answer
Who is your third largest auto carrier? What is your annual premium with them?
Your answer
Agency Trust Account Information – insured payments will be deducted from this account when agency sweep is selected as a payment option. I authorize Covercube Insurance Solutions LLC to deduct payments from this account as the agency receives payments from our mutual policyholders. I am aware policyholders can make payments directly on
covercube.com
or on the Covercube app. Please enter your Bank Name, Routing Number and Account Number.
Your answer
Commission Account Information – commission will be paid to your agency using this account. Please enter your Bank Name, Routing Number and Account Number.
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Covercube Insurance Solutions LLC.
Report Abuse
Forms
