The following items are required, and will need to be attached below, in order to complete your registration Sub-broker Agreement Errors & Omissions Declarations ($1M Limit) Copy of Agency Licenses List of Agency Locations and Contact Details Completed/Signed IRS W-9 Form Completed/Signed ACH Authorization Form Download CannGen Producer Agreement Download CannGen Profile Set Up Download CannGen CheckWriter ACH Form Download W-9 Form Mailing AddressStreet* City* State* Zip* Agency ContactAgency Legal Name* Phone#*Agency DBA (if any) Fax # Applicant First Name* Email Address* Applicant Last Name* Website Business InfoFederal ID#* Total Staff*Agency License #* Number of Active Producers*Year Established* Type of Business* Individual/Sole Proprietor Corporation Partnership Other LLC Licenses Held* Property & Casualty Surplus Lines Life & Health Other Key Personnel InformationPlease provide contact details for all key personnel including Principals and Agency Owners.Name Title Email PhoneAgency Mix of BusinessIf no business is written in either Personal or Commercial lines, please provide an "N/A" in the fields as required.Top 5 Personal Lines Carriers Top 5 Commercial Lines Carriers Top 5 Lines Written (eg: Auto, Home, GL, etc.) How did you hear about CannGen Insurance Services?*--Select--Carrier ReferralAgency ReferralMyNewMarketsLinkedInNWIS Email ContactTradeshow/Special EventOtherWhich One? Attach and Upload DocumentsBrowse to your local file(s) and use the upload button to submit required files with your registration form.Sub-Broker Agreement (Completed and Signed)Accepted file types: gif, jpg, png, tif, txt, rtf, pdf, doc, docx, xls, Max. file size: 2 MB.Errors & Omissions Declaration ($1 Million Limit)Accepted file types: gif, jpg, png, tif, txt, rtf, pdf, doc, docx, xls, Max. file size: 2 MB.Copy of Agency License(s)Accepted file types: gif, jpg, png, tif, txt, rtf, pdf, doc, docx, xls, Max. file size: 2 MB.List of Other Agency Locations and Contact DetailsAccepted file types: gif, jpg, png, tif, txt, rtf, pdf, doc, docx, xls, Max. file size: 2 MB.W-9 Form (Completed and Signed)Accepted file types: gif, jpg, png, tif, txt, rtf, pdf, doc, docx, xls, Max. file size: 2 MB.
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