Prize Insurance Broker Application Form

Please complete the following form. We will be in contact with you to discuss your application.

* Required Fields
*   First Name
 
 
*   Last Name
 
 
*   Company Name
 
 
*   Address
 
 
*   City
 
 
*   State/Province
 
 
*   Zip/Postal Code
 
 
*   Country
 
 
*   Work Phone
 
 
*   Fax Number
 
 
*   Email Address
 
 
*   I agree with the Broker Application Terms and Conditions below.
 
 
Yes.
 
 


Broker Application Terms and Conditions
  1. I am a licensed Insurance Broker.
  2. My initial rate of gross commission is 10%. I agree to the stated gross commission.
  3. I understand that I will pay all premiums as outlined on the invoice and in accordance with the stated policy payment requirements.
  4. I agree I will be doing business only in those jurisdictions whereby I have a legal right to and that I accept full and complete responsibility for the same.
  5. I agree to file any and all taxes and that are required to execute the business I will bind on the site in accordance with Lloyd's of London insurance coverage.
    6.