QuoteFirst Application - Guardian Insurance Wholesalers

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Agency Application

"*" indicates required fields

Agency Name*

DBA (if applicable)

Agency Website*

Agency Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What year did the agency start?*

Please select all states the Agency conducts business*

Main Contact Name*

Main Contact Email*

Main Contact Phone*

Accounting Contact Name*

Accounting Contact Email*

Accounting Contact Phone*

Do you have other agency contacts you would like to provide? This will give them access to Guardian's Agent Portal for online quoting/binding.*

Yes

No

Agency Contacts

First and last name

Email Address

Phone Number

Please upload a copy of your E&O Dec Page and W9*

Drop files here or

Max. file size: 256 MB.

Please upload a copy of your agency residence license*

Drop files here or

Max. file size: 256 MB.

Page: /

Have you been convicted of any felonies in the last 5 years?*

Yes

No

Have you or your agency had any disciplinary action from the Department of Insurance?*

Yes

No

Please provide details on the felony(ies)*

Please provide details on the DOI action*

Authorized Agent*

Date*

If you have any questions call us at: 800-325-9059 x102.