Appointment Inquiry

Thank you for your interest in becoming appointed with CannGen Insurance Services. Please complete the below questionnaire, and a member of our leadership team will be in contact with you shortly to follow up.

Principal Contact Name(Required)

First Last

Principal Contact Title(Required)

Agency Name(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Enter Email Confirm Email

Phone

Are you a Wholesaler or a Retail Agent?(Required)