Become A Producer

If you are interested in becoming a producer for Woodus K. Humphrey & Co., Inc., please complete the form below and
click 'Send'. Upon receipt of your application, we will review your submission and contact you to discuss an agreement.

Full Agency Name:*          

Business Type:*                

Corporation

Partnership

Individual

Tax ID (or SSN):              

Street Address:               

Mailing Address:*            

City:*     State:*    ZIP:*

E-mail Address:*             

Telephone Number:*        

Fax Number:                   

Agency License Number:  

Year Established:*         Number of Producers: 

Total Volume last three (3) years:*

  Current Year       1st Year Prior      2nd Year Prior
   

Does your agency operate as a:*

Retailer

Wholesaler / Broker

General Agent

Combination

Please indicate %:*
% Retail                  % Wholesale / Brokerage    % GA Binding Authority
  

During the last five (5) years, has this agency acquired/merged with another, or changed names:*

Yes

No

If yes, please describe:

Is this agency engaged in, owned by, associated or affiliated with, or controlled by any other business interest:*

Yes

No

If yes, please describe:

Do you maintain an E & O?:*    

Yes

No

Please provide E & O carrier name:*     

Please provide E & O limit:*                   

Please provide E & O expiration date:*   

Accounts Payable Officer: 

Bank Name:                    

Bank Address:                  

Bank City:                       

Bank State:                             Bank ZIP: 

Bank Officer's Name:         

 Companies your agency is appointed by (3 required):*

  Name                                      City & State                                 Years Represented   
          
          
          

Completed By:*              

* denotes required field