Broker Appointment Form Brokerage Name* EIN* Broker License #* NPN Mailing Address* Physical Address Phone Email Website Principals / Owners Name % Ownership Name % Ownership Gross Premium Volume Commercial Auto NYC Livery Metro & Upstate Livery NEMT BOP/CPP Other Current Carriers List all current carriers with annual premium, LOB, commission, and book Additional Info Years selling auto insurance % of business in auto insurance Other Affiliations Compliance Questions Has your license ever been suspended or revoked?YesNo Have you ever been convicted of a felony?YesNo Are you involved in any lawsuits?YesNo Any E&O claims or regulatory actions?YesNo If Yes, please explain Commitment to Maya Expected business by region / line Business plan / Sales process Upload current premium statements (PDF, XLS) Additional Remarks
