Membership Application

Interested in becoming a member of our insurance network?

Please fill out our new member questionnaire, and we will contact you as soon as possible. We’d like to hear from you if your agency fits all the required criteria.

Agency Name

In Business Since

Your Name

City

State

Website Address

Phone Number

Email Address

Premium Summary / Total Written Premium

Total Commercial Lines

Premium - All Carriers

Total Personal Lines

Premium - All Carriers

Agency Total Revenue

Number of Employees

(full time equivalent)

If currently a member of another network or aggregator, name of group:

If currently a captive agency, name of captive carrier:

If other, specify

How did you hear about us?

Remarks

Please expand on why you would like to join United Valley.