Maya Assurance Company

Broker Appointment Form

    Company Licenses:

    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.

    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***

    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.