Welcome
to the PURE Broker Enrollment Inquiry Form
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Please fill out all required fields
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Contact Information
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*
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Is Mailing Address same as Physical address?
Yes
No
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*
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Is Mailing Address same as Physical address?
Yes
No
Mailing Address
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Company Information
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--Select Entity Type--
C Corporation
S Corporation
LLC
Partnership
Individual
Individual Sole Proprietor
Single Member LLC
Trust-Estate
LLC S-Corp
LLC C Corp
LLC Partnership
Other
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Does your firm use an Agency Management System?
Yes
No
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-- (if yes) Which System? --
AMS
Applied
Proprietary
Other
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--Select Tax ID Type--
FEIN Number
Social Security Number
Undisclosed
*
*
--Select Entity Type--
C Corporation
S Corporation
LLC
Partnership
Individual
Individual Sole Proprietor
Single Member LLC
Trust-Estate
LLC S-Corp
LLC C Corp
LLC Partnership
Other
*
*
*
*
Does your firm use an Agency Management System?
Yes
No
*
-- (if yes) Which System? --
AMS
Applied
Proprietary
Other
*
--Select Tax ID Type--
FEIN Number
Social Security Number
Undisclosed
*
Agency Administrator
Primary Systems Administrator
--Select Prefix--
Mr.
Ms.
Mrs.
Dr.
Prof.
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*
--Select Suffix--
Jr.
Sr.
II
III
IV
V
VI
DDS
Esq.
JD
MD
PHD
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Primary Systems Administrator
--Prefix--
Mr.
Ms.
Mrs.
Dr.
Prof.
*
*
--Suffix--
Jr.
Sr.
II
III
IV
V
VI
DDS
Esq.
JD
MD
PHD
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Key Personnel
Error!
Last Name is required.
-- Select Role --
Admin
Accounting Contact
Claims Manager
Client Services
Licensing Contact
Personal Lines Manager
Principal
Producer
Sales Marketing
Error!
Last Name is required.
*
-- Select Role --
Admin
Accounting Contact
Claims Manager
Client Services
Licensing Contact
Personal Lines Manager
Principal
Producer
Sales Marketing
*
*
*
*
Licensing Questionnaire
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Has your firm ever had a license denied, suspended or revoked?
Yes
No
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Does your firm have complaints pending with any regulatory body?
Yes
No
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Has your firm ever had a license denied, suspended or revoked?
Yes
No
*
Does your firm have complaints pending with any regulatory body?
Yes
No
Errors & Omissions Coverage
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*
[
12/21/2024
]
*
*
[
12/21/2024
]
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*
Has your company had any Errors & Ommissions claims in the past 5 years?
Yes
No
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*
[
12/21/2024
]
*
*
[
12/21/2024
]
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Has your company had any Errors & Ommissions claims in the past 5 years?
Yes
No
Total In-Force Premium
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*
*
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Largest Admitted Personal Lines Markets
Please list your Admitted Personal Lines Markets
1
*
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
*
*
2
*
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
*
*
3
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
4
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
Please list your Admitted Personal Lines Markets
1
*
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
*
*
2
*
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
*
*
3
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
4
-- Select Carrier --
American Family Insurance Group
Auto- Owners Group
Hartford Fire & Casualty Group
National General Insurance/Allstate
MetLife / Farmers Group
Safeco/Liberty Mutual
Travelers Group
Other
High Net Worth Personal Lines Markets
Please list your High Net Worth Markets
1
*
--Select Carrier Name--
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
*
*
2
*
--Select Carrier Name--
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
*
*
3
--Select Carrier Name--
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
4
--Select Carrier Name--
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
Please list your High Net Worth Markets
1
*
-- Select Carrier Name --
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
*
*
2
*
-- Select Carrier Name --
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
*
*
3
-- Select Carrier Name --
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
4
-- Select Carrier Name --
AIG Private Client Group
CHUBB
Cincinnati Executive Capstone
Nationwide Private Client
Vault
Wholesaler
Other
How did you hear about PURE?
*
-- Select an Option --
LinkedIn or Social Media
Direct Mail
Print or News Article
Pureinsurance.com
Referred by a broker of PURE
Referred by a member of PURE
Other
*
-- Select an Option --
LinkedIn or Social Media
Direct Mail
Print or News Article
Pureinsurance.com
Referred by a broker of PURE
Referred by a member of PURE
Other
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