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Menger Underwriting Services, LLC
REGISTER: CREATE AN ACCOUNT OR EDIT EXISTING ACCOUNT

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Agency ID Number (enter your FIEN #):

Agency Name:

Mailing Address
Mailing Address
City State Zip
Phone Fax E-mail
Tax Payer ID# This will be your Agency ID Number
Legal Entity

Please enter or edit contacts for your organization.

Last Name
First Name
Contact Type
Title
Phone or Ext
Fax
Email Address

Please provide us with information about your Errors & Omissions Coverage.

E&O Insurance Co.
E&O Policy Number
E&O Expiration Date
E&O Limit (Per Claim)
Deductible (Per Claim)

Please answer these questions about your Agency.

Producer Profile  
1. Have you ever had a license denied or revoked by any state (except for failure to pass initial examination)? yes  no 
2. Are you, as an agent, indebted to any insurance company, general agent, manager, or user, or are any of the same claiming that you are indebted to them? yes  no 
3. Have you filed for bankruptcy, court protection, or reorganization during the past five years, or is any bankruptcy proceeding filed by you still pending? yes  no 
4. Have you ever been convicted of a felony or diciplined, fined, or censured by a state insurance department or any regulatory body or court? yes  no 
5. Are you now the subject of any complaint, investigation, or proceeding that could result in a yes answer to any of the previous questions? yes  no 

REMEMBER - Sign and Fax a Copy of the Brokerage Agreement