Insurnace Agent Business Plan

							                                                                                                      Executive Peace of Mind, Worldwide.



Instructions for Insurance Agent Appointments
 1.    Complete and sign both sections of the enclosed XN Risk® form:

       "Brokerage Information for Appointment "and "Agent Appointment & Licensing Worksheet" [US-8-14-GTC (12-02)]. PLEASE
       NOTE THAT THE BROKERAGE MUST HOLD A VALID E & S LICENSE IN ALL STATE(S) IN WHICH YOU WISH TO BIND
       COVERAGE.
 2.    Attach a copy of the Life & Health and Property & Casualty license(s) for the state(s) in which appointment is being sought. The
       license(s) must be current and not expiring within 60 days of request for appointment.

 3.    Attach a copy of the Excess and Surplus Lines license(s) for the states in which you expect to broker business.

 4.    Please include a list of all employees names and email address who will require a username and password to access our
       online quote facility.
 5.    Mail the completed "Brokerage Information for Appointment" and "Agent Appointment & Licensing Worksheet" form [US-8-14-
       GTC (12-02)] and license copies to:

       XN Risk®
       Attn: Phillip Hoyt
       10 King Street East, Suite 1000
       Toronto (Ontario) Canada M5C 1C3
       (416) 340-6430

Your appointment paperwork will be processed and you will be assigned a XN access code that should appear on all business
submissions to assure proper commission payments. Mailers are also available to include in mailings to potential clients.

If you have any questions regarding coverage, please call (416) 340-6430.


Phillip Hoyt
Managing Director
XN Risk®




                                                                           XN Risk®
                                                    10 King Street East, Suite 1000, Toronto, ON M5C 1C3
                                    Tel: (416) 340-6420 - Fax: 1-877-908-1837 - Email: uw@xnrisk.com - www.xn.com
                                                                                                           Executive Peace of Mind, Worldwide.



Brokerage Information for Appointment
Applicant Information
First name:                                                                       Last name:
What are your annualized D&O and EPL W/P (including Crime
                                                                                 ►
and Fiduciary) which is eligible for this facility?
List your top five markets for these coverages: ▼
1.
2.
3.
4.
5.
Attach a copy of your Property & Casualty license for the state(s) in which you are licensed.

Attach a copy of your Excess and Surplus lines license for the state(s) in which you expect to broker business.
(You must have a E&S license for all state(s) in which you plan to bind coverage and make appropriate filings. XN Risk is not
responsible for this activity.)

Provide evidence of insurance for Insurance Agents and Brokers Professional Liability - $1,000,000 minimum limit required.
Company Information
Company name:
Company address:                                                                 City:
State:                             Zip code:                                     Country:
Office telephone number:                                                         Office fax number:


                                                                                                                          New license request
Agent Appointment & Licensing Worksheet                                                                                   Date: (yyyy-mm-dd) ____________
General Information                                                           (Applicant’s name as it appears on the state license – Attach copy of license)

Applicant’s first name:                                                           Last name:
Address:                                                                         City:
State:                             Zip code:                                     Country:
Agency name:
Agency address:                                                                  City:
State:                             Zip code:                                     Country:
Is entity licensed in requested state?            yes          No                 Producer code / SA:


Submitted by:                                                                     Processed by:
Comments:




US-8-14-GTC (12-02)

                                                                                XN Risk®
                                                         10 King Street East, Suite 1000, Toronto, ON M5C 1C3
                                         Tel: (416) 340-6420 - Fax: 1-877-908-1837 - Email: uw@xnrisk.com - www.xn.com