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PIIB Carrier Intake Form

Interested in becoming a new market for PIIB? Please complete this intake form with as much detail and information as possible. New carrier requests will be evaluated quarterly by PIIB, the Board of Directors, and our Affiliates.
1.Your Name:(Required.)
2.Contact Phone #:(Required.)
3.Contact Email Address:(Required.)
4.Name of Company:(Required.)
5.Are you a Carrier or Wholesaler:(Required.)
6.If a wholesaler, please list the top carriers you have access to:(Required.)
7.Are your products Preferred or Excess & Surplus Lines:(Required.)
8.What lines do you offer:(Required.)
9.If Commercial Lines, what lines of business do you offer?(Required.)
10.If Personal Lines, what lines of business do you offer?
11.What is your rating on AM Best or Demotech:(Required.)
12.What is your commission structure:(Required.)
13.How many agencies do you currently have appointed:(Required.)
14.How many networks do you currently work with:(Required.)
15.What is your current overall premium:(Required.)
16.What type of set-up do you offer:(Required.)
17.Do you have volume commitments:
18.If yes to #17, would you consider a lower, agreed upon volume commitment for PIIB affiliates, considering the group overall:
19.What does your appetite consist of? Please be as specific as possible:(Required.)
20.Which of our states do you currently write in:(Required.)
21.Who are your main competitors:(Required.)
22.Do you offer profit sharing or commission overrides:(Required.)
23.What is the difference between agencies accessing you via PIIB vs directly:(Required.)
24.What value do you bring to PIIB that is different from other Networks:(Required.)
25.How did you hear about PIIB:(Required.)