Get Appointed | BPIS Insurance Services

STEP 1 OF 5

Agency

Complete the information used in your BPIS producer questionnaire.

Electronic signing is being activated. You can prepare and save your application; signing will open once setup is complete.

Legal agency name *DBA namePhysical street address *City *State *ZIP code *Mailing address, if differentWebsiteAgency phone *FaxAgency email *Agency established *

Agency entity *

How did you hear about BPIS? *

Representative / referral details

Owners and principals

Name * Title / position * Address, city, state, ZIP *

Key agency contacts

Name * Title / position * Licensed? * Email *

Accounting / policy delivery email *

Authorized agency signer

Full name *Title *Signer email *