In order to complete your contracting request, please complete the following contracting questionnaire. The information in this questionnaire will be input in to a contracting system, Sure LC, at Hansen Brokerage Services that stores your information and carrier contracting forms. In the future, as you contract with new carriers, this stored information is used to complete contracting paperwork on your behalf, increasing speed and efficiency. Most of our carriers participate in this contracting system, but not all.
By signing the signature page, you are attesting the information you are submitting is true and accurate and you authorize Hansen Brokerage Services to submit your information through the contracting system to selected carriers.
Please submit the following to our office:
- Completed Questionnaire – ( DOWNLOAD QUESTIONNAIRE HERE )
- If you answered yes to any background questions, please submit a letter of explanation
- Signed signature page
- Completed EFT form (many carriers require EFT)
- Copies of your agent and/or agency state insurance licenses
- Copy of your E&O coverage
- Copies of AML completion if taken through a Broker Dealer or CE firm. If taken through LIMRA, no need for copies.
Please email all documents to Lisa Mills at firstname.lastname@example.org or fax them to 616-940-4033.
Please feel free to call Lisa Mills with any questions or concerns at 1-800-746-3544.