New Agents

New agents sub header.

Vintage Underwriters welcomes new partners!

If you are interested in writing business with Vintage Underwriters please complete the online Agency Information Form below, or you may download the PDF form here and email the completed form to marketing@vintageunderwriters.com.

Along with this form, you will need to submit the following information:

Copy of Insurance License for each licensed agent/broker in your office as required by the State Insurance Department. Please Note: If you are signing up under a business name, that entity must be licensed with the Department of Insurance otherwise you must sign the agreement in your personal name.
Contact Roster for all agents/brokers in your office, as well as any additional staff with whom we would conduct business (CSRs, accounting, claims, etc)
Copy of your complete E&O Policy showing E&O coverage in place with minimum limits of $1,000,000 and clearly stated Retroactive Date

New Agents

Agency *

Address *

City *

State *

Zip *

Phone *

Website/URL

Fed ID / SSN *

Organizational Type

Individual

Partnership

Corporation

Other

Names of Owners

Owner Name

Title

% Owned

Add Remove

*ATTACH COPY OF GENERAL LINE P & C LICENSE(S) FOR AGENCY AND PRINCIPALS*

Maximum upload size: 5MB

Years in Business *

States in Which You Are Licensed *

During the past five years, has the name of the agency been changes, or has any other business been purchased, merged, or consolidated with the agency?

Yes

If YES - provide details.

Is the agency engaged in any other business?

Yes

If YES - provide details.

Annual Premium Volume Last Year - $

Surplus Line Volume Last Year - $

Total Number of Staff

Principals

Producers

CSRs

Other Staff

Total

% of Business by Line

Commercial

Personal

Life/Health

Other industry

List Main General Agencies with whom you place business

General Agency

Add Remove

List Standard companies represented

Standard Company

Add Remove

E&O Coverage?

Yes

Attach Copy of E&O Policy

Maximum upload size: 2MB

Have any E&O claims been made during the past 3 years against you?

Yes

If yes, attach a statement giving details.

Maximum upload size: 2MB

Printed Name of Agency Principal *

Title *

Thank you for your interest in Vintage Underwriters.

If you have any questions, please contact us at (713) 773-6400 x 104 or (800) 488-5771.

Contact Information for Texas Department of Insurance:
Texas Department of Insurance
PO Box 149104
Austin, TX 78714-9104
Phone: (800) 252-3439 / Fax: (512) 475-1771
www.tdi.state.tx.us