Welcome


to the PURE Broker Enrollment Inquiry Form

To begin the application process for becoming a PURE broker, we first ask for some information about your business. Once your application is reviewed, a member of our Sales team will reach out to discuss potential alignment and determine whether a partnership is the right fit. If you have additional questions, email sales@pureinsurance.com.
Fields marked (*) are required fields

Contact Information

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  • *Is Mailing Address same as Physical address?
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Is Mailing Address same as Physical address?

Company Information

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    Are you a wholesale broker?
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    Is your agency a member of an agency networks, alliance, aggregator, cluster, or market access provide?
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Are you a wholesale broker?
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Is your agency a member of an agency networks, alliance, aggregator, cluster, or market access provide?

Agency Administrator

The Agency Administrator is responsible for secure lifecycle management of user access to PURE’s broker portal (onboarding, changes, termination). This role requires controlled access to employee licensing data (NPN, DOB, SSN) and must implement approved safeguards such as MFA, encryption, audit logging, periodic access reviews and adhere to privacy requirements.
  • Primary Systems Administrator
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Primary Systems Administrator

  
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Key Personnel
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Licensing Questionnaire

  • * Has your firm ever had a license denied, suspended or revoked?
  • * Does your firm have complaints pending with any regulatory body?
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Has your firm ever had a license denied, suspended or revoked?
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Does your firm have complaints pending with any regulatory body?

Errors & Omissions Coverage

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  • *[ 4/1/2026 ]
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  • *[ 4/1/2026 ]
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  • * Has your company had any Errors & Ommissions claims in the past 5 years?
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*[ 4/1/2026 ]
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*[ 4/1/2026 ]
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Has your company had any Errors & Ommissions claims in the past 5 years?

Total In-Force Premium

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High Net Worth Personal Lines Markets

High Net Worth is defined as accounts with a home with Coverage A greater than $1M.
  • Please list your High Net Worth Markets
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Please list your High Net Worth Markets

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Largest Admitted Personal Lines Markets

  • Please list your Admitted Personal Lines Markets
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Please list your Admitted Personal Lines Markets

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How did you hear about PURE?

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