Thank you for your interest in the Lancer Insurance Company. This form will provide important information needed for us to respond promptly. One of our corporate marketing professionals will contact you shortly after receiving your form.

(* Required information)
*Agency Name:
DBA:
*Contact Name:
*Address:
*City:
*State:
 *Zip:
*Office Phone:
Cell Phone:
Fax:
*Email:
Website:
*Does your Agency have a Premium Trust Account?
Yes No
*Does your Agency have an Errors & Omissions Policy?
Yes No
*What are the limits? $
*What is the deductible amount? $
*Does your Agency have Fidelity Coverage?
Yes No
*What are the limits? $
*Your Agency's Estimated Annual Premium Volume:
$ Program Type Carrier
$ Program Type Carrier
$ Program Type Carrier
Type of License: Broker      Agent    Both
List States of License:
Do you Co-Broker any of your Accounts?
Yes No
Reasons for interest in Lancer as a market:
Other Lancer Product(s) Affiliation:
How did you initially hear about Lancer Insurance Company?
Comments:
 

 

 
               
 
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