Broker Profile – Maya Assurance Company

Broker Appointment Form

Broker Name*

EIN*

Mailing Address

Street*

City*

State*

ZIP*

Physical Address

Is Physical Address same as Mailing Address?

Street*

City*

State*

ZIP*

Additional Address

Street

City

State

ZIP

Additional Address

Principals & % Ownership

Name*

Ownership*

Add Principals & % Ownership

Main/Primary Contact

Accounting Contact

First Name *

Last Name *

Email *

Direct Phone *

Website

Company Licenses

Do Not Have Company License

Type *

License # *

State *

Expiration Date *

Add Company Licenses

Producers/Employees

Name

Phone No. & Ext.

Email Address

License Type

License #

State

Expiration Date

Add Producers/Employees

Top 3-5 Carriers by Premium

Carrier*

Annual Premium*

Line(s) of Business*

Commission*

% of Book*

Gross Premium Volume Distribution

Line of Business*

Current Year Gross Written Premium*

Additional Information

Question

Has any insurance carrier suspended or terminated your account?*YesNo

Has your brokerage or any of its Owners, Principals, Partners, or Employees had a company or individual license suspended or revoked?*YesNo

Has any Principal, Owner, or Partner been convicted of a crime?*YesNo

In the past 5 years, are there any pending judgements or litigation exceeding $10,000 against the brokerage or any of the principals?*YesNo

Has your brokerage or any principal, Owner, or Partner ever filed or bankruptcy or re-organization under bankruptcy law?*YesNo

Have you or your brokerage ever been party to any error & omissions suit in the last 5 years?*YesNo

Details on any above yes answers

Commitment to Maya

To open your office to write with Maya Assurance, we would like to have a commitment of business you plan to bring to us. The amount of business you bring to us among our various lines of business (listed below) will affect your commission rates. Our top brokers earn more commission.

Annual Premium*

Line(s) of Business*

Errors & Omissions

Carrier*

Policy #*

Effective Date*

Expiration Date *

Limit Per Claim*

Aggregate Limit*

You will be required to provide copies of all licenses and your current Errors & Omissions declaration page or certificate, with an insurance company that has a AM Best rating of A-7 or better, so we may approve to activate your account. The Broker Agreement will need to be signed by both parties and returned to us.

Required Documentation

Completed Appointment Form
Errors & Omissions Policy
Company Licenses
Producer Licenses
W9

User List for Avante (Quoting, Policy & Accounting System)

API key from USD GoPay/MVRnow

Signed Broker Agreement

It is your responsibility to provide to us renewals and changes in personnel to remain in compliance with the Broker Agreement.

I hereby affirm, under penalty of perjury, that the information provided in this application is true and accurate. Maya Assurance Company conducts background checks on all Brokerages, their Owners, Principals, and Partners. Your signature below authorizes Maya Assurance Company to conduct such an investigation.

Maya Avante Quoting & Policy System Signup

Please list all individuals who will need access to our quoting & policy system. Accounting information and the ability to make payments is also through this system, please be sure to include those members of your team as well.

**Please note that every user MUST have a unique email ID for us to create login credentials. All users below must have a different email than the one listed above***

First Name

Last Name

Phone # & Extension

Email Address

Add More

A. Bank Information for ACH

Bank Name

Account Number

Routing Number

B. API Key for MVRnow/USD GoPay (to Run MVRs in Avante)

API Key

It is your responsibility to provide to us renewals and changes in personnel to remain in compliance with the Broker Agreement.

I hereby affirm, under penalty of perjury, that the information provided in this application is true and accurate. Maya Assurance Company conducts background checks on all Brokerages, their Owners, Principals, and Partners.

Your signature below authorizes Maya Assurance Company to conduct such an investigation.

Signature*

Name (Printed)*

Date*

Title

Broker Appointment Form

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