Sign Up – Agent

1Personal Info

2Office Info

3Questions / Confirm Submission

Franchise Name*
InsureLine Start Date*
DD slash MM slash YYYY
Year started in the insurance industry?*
Joining us from another company?*
Servicing Role*
If Producer, enter your total Policy Volume from the past 12 months
Will Producer require a separate branch to be added into Epic?*
- Yes
- No
- Unsure
List anyone else who should receive access to this Producer branch?
Will Producer have access to all carriers
- Yes
- No
Please list all carriers this user requires access to for quoting in Epic and Rating Services
Will Producer / CSR be salary, commission or both*
- Salary
- Commission
- Both
Please provide commission agreement for Producer / CSR
List anyone who should receive access to users Tasks, Workflows and Activities
What Broker Management System are you most familliar with?
Do you require an Applied Epic license (monthly costs apply)?*
- Yes
- No
- Unsure
Do you require an Electronic Signature (PandaDoc) license (monthly costs apply)?*
- Yes
- No
- Unsure

Your Name (person filling out form)
First Last
Your Email (person filling out form)
If you have any questions about this sign up form or instructions for our setup team, please include them here
"I accept" the InsureLine Internet Usage Policy*
"I accept" the InsureLine Internet Usage Policy*
- Yes