Get Appointed

To write workers’ compensation or any type of coverage through Omega Insurance Solutions, Inc. your agency must be contracted with Omega Insurance Solutions, Inc. Fill out the form below to submit your application for consideration for appointment.

Agency Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Agency Phone(Required)

Agency Email(Required)

Agency Principal Name(Required)

First Last

Principal Email(Required)

Other Agency Contacts

Name	Email	Actions

There are no Contacts.

Does your agency act as a wholesaler or MGA for any insurance

Yes

Omega Insurance Solutions only works with retail insurance agencies. If you are a wholesaler or MGA we must have more information before we can consider. If you want to proceed, please complete this application.

Carriers or MGAs Used (Add up to 5)

Carrier Name	Actions

There are no Carriers.

Lines of Business

Line of Business	Actions

There are no Entries.

How did you hear about Omega?(Required)

Referral from another agent or broker

Referral from a carrier

Met at a convention or trade show

Internet search

Email marketing

Other

License and Legal Information

E & O Carrier (attach a copy of E&O Declarations Page or Certificate of Insurance at bottom of form)

E & O Policy Number

E & O Expiration Date

Licensed Producers for Agency (please enter primary producer first)

Date Agency Established

Is your agency a corporation or LLC?

Yes

Please Attach Declarations Page of your E & O Policy

Max. file size: 128 MB.

Primary licensed producer for this agency:

License Number

States Licensed

Upload Copies of Producer's License

Max. file size: 128 MB.

Please type your full name here to sign(Required)

Name

This field is for validation purposes and should be left unchanged.

74838

Get Appointed

License and Legal Information

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