American Modern

Are you interested in an appointment with American Modern?

We appreciate your interest in American Modern. To get started, please complete the following questionnaire so we can match you with the appropriate member of our team for further discussions.

This form is best viewed in Google Chrome or Microsoft Edge.

 

Principal Information 

 
 
Principal First Name*
 
 
Principal Last Name*
 
 
Principal SSN (numbers only)*
 
 
Please enter phone numbers as numbers only in the following format (5555555555) 
 
 
Office Phone*
 
 
Principal Date of Birth (mm/dd/yyyy):*
 
 
 

Contact Information

 
 
 
First Name*
 
 
Last Name*
 
 
Suffix
 
 
Email*
 
 
Your Phone*
 
 
Job Title*
 
 

Agency Information

 
Agency Name (As Licensed)*
 
 
DBA (if different than name as licensed)
 
 
Federal Tax ID # (numbers only)
 
 
Company Email Address*
 
 
Agency Website*
 
 
NPN (National Producer Number)*
 
 
Agency Address*
 
 
Address Line 2
 
 
City*
 
 
State*
 
 
 
Zip Code*
 
 
County*
 
 
Country*
 
 
Mailing Address (if different)
 
 
Mailing Address 2
 
 
Mailing Address City
 
 
Mailing State
 
 
Mailing Zip code
 
 
Agency Type (Select Most Appropriate)*
 
 
If Other Describe
 
 
Name of Aggregator Group if Selected Above
 
 
Agency Business Model*
 
 
 
 
Number of Employees
 
 
Years Established (as an agent)
 
 
 
List States Where You Are Currently Writing:*
 
 
Projected American Modern Premium (Production Goal)*
 
 
Personal Lines Percentage (number only)
 
 
Commercial Percentage (numbers only)
 
 

E&O Information


Please enter dollar values as numbers only in this format (1000000) 
E&O Carrier Name*
 
 
E&O Policy Number*
 
 
E&O Policy Limit*
 
 
E&O Effective Date*
 
 
E&O Expiration Date*
 
 
 

Carriers Represented

In the first column list the top 3 primary personal lines carriers.  In the second column enter the premium volume of each of the carriers on the left.

 
Primary Personal Line 1 - List Carrier
 
 
Primary Line 1 Premium Volume in $
 
 
Primary Personal Line 2 - List Carrier
 
 
Primary Line 2 Premium Volume in $
 
 
Primary Personal Line 3 - List Carrier
 
 
Primary Line 3 Premium Volume in $
 
 

Specialty Carriers Represented

In the first column list the top 3 specialty personal lines carriers.  In the second column enter the premium volume of each of the carriers on the left.

 
Specialty Personal Line 1 - List Carrier
 
 
Specialty Line 1 Premium Volume in $
 
 
Specialty Personal Line 2 - List Carrier
 
 
Specialty Line 2 Premium Volume in $
 
 
Specialty Personal Line 3 - List Carrier
 
 
Specialty Line 3 Premium Volume in $
 
 

General Information

 
Have you previously worked with/represented American Modern?
 
Yes
No
 
 
With Whom
 
 
 
 
 
 
Opt-in for communications from American Modern
 
 
 
 
 

Agents That Will Need Access

ONLY list licensed agents within the office that will be writing American Modern Products.  If the Principal listed on the previous page is a licensed agent, their information does not need to be re-entered here.  If you do not have additional agents to add, proceed to the bottom of the form and click Submit.

 
 
 
 

Agent 1

 
First Name (as licensed)
 
 
Last Name (as licensed)
 
 
Email
 
 
Social Security Number
 
 
Job Title
 
 
 
 

Agent 2

 
 
 
First Name (as licensed)
 
 
Last Name (as licensed)
 
 
Email
 
 
Social Security Number
 
 
Job Title
 
 
 
 

Agent 3

 
 
 
First Name (as licensed)
 
 
Last Name (as licensed)
 
 
Email
 
 
Social Security Number
 
 
Job Title
 
 
 
 

Agent 4

 
First Name (as licensed)
 
 
Last Name (as licensed)
 
 
Email
 
 
Social Security Number
 
 
Job Title
 
 
 
 

Agent 5

 
 
 
First Name (as licensed)
 
 
Last Name (as licensed)
 
 
Email
 
 
Social Security Number
 
 
Job Title
 
 
 
 

Office Employees That Will Need Access

Please list any office employees that will need access.  If you do not have additional employees to add, please proceed to the bottom of the form and click Submit.

 
 
 
 

Employee 1

 
First Name
 
 
Last Name
 
 
Email
 
 
Date of Birth
 
 
Job Title
 
 
 
 

Employee 2

 
 
 
First Name
 
 
Last Name
 
 
Email
 
 
Date of Birth
 
 
Job Title
 
 
 
 
 
 
 
 
 
 
 
 

CAPTCHA

Tell us you're not a robot by sliding the lock from left to right.  Once the form is unlocked, click Submit.