Agency name:

Contact Person:

Mailing& Street Address:

City/State/Zip Code:

Phone: Fax:

Year Agency Established:    Tax ID# or SS#:

E&O Coverage: Company: Policy #:

Limit: $  Exp. Date:

Print and Fax this form with a photocopy of your Agency Certificate of License and all individual producer Licenses to 620-442-3342.

Producer Name:

Home Address:

Individual Social Security #:   Date of Birth:

Email Address:

If you have any questions you can call 620-442-0400 ask for Rhonda Pike or
email questions to rpike@unitedagencyks.com