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Colonial Lloyds welcomes new agents in Texas. Please complete this brief form and click submit below for a prompt reply.

New Agent Information Form
* Required Fields

*Agency Name:
DBA
(if different than above):
Mailing Address
  *Address:
  *City:
  *State/Zip:   -
Physical Address (if different than above)
  Address:
  City:
  State/Zip:   -
*Business Phone: - -
Fax Phone: - -
*Email:
Website:
Agency Principal(s):
Appointed Agent:
*License #: License Exp Date:
Contact Person:
Name of E & O Company: Effective Date:
*Years in Business: Years in Present Location:
Personal Lines Volume:
Current Personal Lines Companies:
  Top 5




Are you currently or have you previously been appointed to write coverage with Colonial Lloyds.
  Yes No
  If yes, please list the name of the Managing General Agents

 
Additional Notes:



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