Agency Appointment
Please fill this form out as completely as possible.  This information will be used to populate our Agency Qualification Form only.  After clicking submit, the form will be sent to Mendota's Business Development Manager for review and follow up.   Fields marked in blue are required.
For which state are you requesting an Agent / Broker appointment?
Agency Name
Business Address
County   State   Zip
Mailing Address
(if different)
County  State  Zip
Phone Number  Fax Number 
Primary Email
Website Address
DOI License
 Year Agency Established 
Taxpayer Id
Legal Name
Tax ID / SSN
Principal(s) Name(s)
Key Contact person(s) responsible for placement of specialty personal lines risk 
List at least two standard companies with which your agency does business.

What is you agency's total annual written premium?
What percentage of your agency volume is non-standard automobile?
List your largest Auto Carriers:
  Company 1 Company 2 Company 3
Company Name
3 Yr. Loss Ratio
Written Premium
Projected first year written premium volume comitment with Mendota?
Must match code above
Security Check: Enter the code above.
If you have any questions, please click here to contact our Contracts / Licensing Department.
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