Online Services

Payment Center

Accepting check, credit card and
automatic withdrawal payments.

Find an agent
or
Find MAPFRE Branch Locations

Application for Agency Appointment

General Information

Note: All fields in bold are required.

Agency:		License #:
Agency Principal(s):		Tax ID:
Street Address:		City:
State:		Zip:
Mailing Address:		Telephone:
Fax:		Email:

Agency Information

Note: Do not use commas or spaces when filling in the information below.

Years in Business:		# of Employees:
# of Licensed:		Total Agency Volume:
Total Agency Volume (Auto):		Non-Standard:
Agency's Total Number of Auto Companies Represented:
Average Number of Auto Apps per Month (previous year):
Average Number of Annual Homeowner Apps:
Primary Company for Standard/Preferred Auto:
Non-Standard Auto:		Homeowners:

How does your Agency advertise (select all that apply):
Yellow Pages Direct Mail TV/Radio Referrals Other

Has your license ever been suspended or cancelled?YesNo

If yes, please explain:
Have you ever been fined by the state?YesNo
If yes, please explain:

Systems

Note: All fields in bold are required.

Management System Name*:		Version #:
* If you do not have a management system, type "None" in the above field.
Upload/Download:	YesNo	If yes, Company:
Rating Software:	FSCOIS/QuoteworksCompany Standalone Website RatingE-Z LynxOther
ZAP/APP:	YesNo	EFT:	YesNo

MAPFRE Insurance℠ is a brand and service mark of MAPFRE U.S.A. Corp. and its affiliate American Commerce Insurance Company of Columbus, Ohio.
The MAPFRE Insurance brand for products sold or marketed by American Commerce Insurance Company has been approved for use by the
Department of Insurance in the following states: Ohio and Indiana