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Agency Profile

Become a JM Wilson Agent

PLEASE NOTE – the following items are required in order to successfully complete the appointment application form below:

  • Current E&O policy information
  • W9 form
  • Consent to run credit report
Only a PDF file under 10.00MB is accepted. If needed, download a new W9 form from the IRS.
Agency’s Primary Physical Address:
Does the agency have additional locations? *
Mailing Address:
States Licensed In:
Ownership

Please ensure ownership percentages total 100%.

Owner

Key Contacts:
Receive Policies and Endorsements
Receive Statements and Billing Communications
Main Contact for Questions/Updates
Additional Contacts:
Contact

Premium Volumes
Please list Wholesalers/MGAs you placed business with last year:
Wholesaler/MGA

How did you learn about JM Wilson? *
Are you a part of an agency network or cluster group? *
Have you spoken with a JM Wilson Underwriter? *
What lines or classes of business will you be looking to JM Wilson for? Select all that apply. *
Would you like to receive a premium finance proposal with qualifying quotes? *
Errors and Omissions Insurance

The above information is true to the best of my knowledge. I authorize JM Wilson to make whatever inquiries they deem necessary to approve this application for appointment to do business with them. Investigation will include a credit report.

A copy of all the information you submitted will be emailed to you.