Thank you for your interest in Nationwide E&S/Specialty.

If you carry a surplus lines license and would like to become a Nationwide E&S/Specialty partner, we want to know more about you. If you meet our eligibility requirements, someone from our team will contact you and provide you with additional forms.

Please note: Agencies selling directly to the public (insured), are not eligible for a direct appointment. You will need to submit your business through one of our appointed agents in your area.

You will be contacted within 10 business days.

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* 1. Today's Date:

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* 2. Company Information

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* 3. How do you operate?

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* 4. Are you surplus lines licensed? If you are not surplus lines licensed, you are not eligible for a direct appointment. Please go back to the Agency Locator to find a general agent in your area.

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* 5. What year was your agency established?

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* 6. Where is your office located?

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* 7. Select the organization(s) of which you are a member:

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* 8. What do you want to bring to Nationwide E&S/Specialty?

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* 9. Do you currently control this book or program?

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* 10. Premium volume of book or program being offered:

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* 11. What is the profitability of the book?

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* 12. What is the loss ratio for the last 3-5 years?

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* 13. Type of paper:

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* 14. Lines of Business:

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* 15. States requested:

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* 16. Do you currently have a binding contract agreement with another surplus lines company?

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* 17. How many years with that company?

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* 18. Do you currently have Errors and Omissions Coverage?

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* 19. First year premium commitment:

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* 20. why are you seeking a contract with NW E&S/Specialty

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* 21. Additional comments:

Completion of this form does not imply you will be appointed to the Nationwide E&S/Specialty Group or any of its member companies. This form is strictly to determine eligibility.

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