Become a partner

Agency Appointment Profile

Thank you for your interest in doing business with Mechanicus Insurance Services LLC. Complete the profile below — on submit we fill your answers into the full Enrollment Kit and open an email to [email protected] for you to attach and send.

✓

Enrollment kit generated

Your completed Enrollment Kit has been downloaded to this device and an email to Mechanicus has been opened for you.

FINISH SENDING YOUR APPOINTMENT REQUEST

Attach the downloaded PDF to the email that just opened:
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Also attach your signed Producer Agreement, W-9, license copies and E&O declaration page.

Send to [email protected] — we'll review and contact you directly.

01 · AGENCY INFORMATION

Agency Name (Tax Filing Name for 1099)

DBA

FEIN #

NPN #

Agency Principal Name

Agency Principal Email

02 · ADDRESSES & CONTACT

Agency Physical Address — Street

City

State

Zip

Mailing address same as physical address

Agency Mailing Address — Street

City

State

Zip

Phone Number

Agency Website

Affiliate / parent / association / membership (if any)

Date Joined

03 · BOOK OF BUSINESS

Breakdown of E&S volume (%)

Commercial

Personal

Transportation

Professional

Premium Volume (current year, approx.)

E&S Premium Volume

Which wholesale brokers and/or MGAs does your agency work with?

04 · DISCLOSURES

Have you or any partner had an agency contract terminated for fraud?

YesNo

Has a department of insurance suspended, revoked, or refused to issue/renew a license?

YesNo

Have you or any partner of your firm filed bankruptcy?

YesNo

If you answered yes to any of the above, please provide state(s) and outcome(s)

05 · ACCOUNTING CONTACT

Accounting Contact Name

Accounting Contact Phone

Accounting Contact Email

On submit we fill your answers into the full Enrollment Kit (profile, Retail Producer Agreement and instructions) and open a pre-addressed email for you to attach it.