Agency Appointment Request

Professional Concepts Insurance Agency, Inc.
DBA Equine World Insurance
1127 South Old 23
Brighton, Michigan 48114-9681
866-954-0555 Toll Free Phone / 866-954-0550 Toll Free Fax
www.equineworldinsurance.com
To download this form as a PDF, click here.

Agency/Broker Profile
Agency Name
Street Address
P.O. Box
City
State		Zip
Phone
Fax
Email
Web Address
	Individual Partnership Corporation
Total Number of Employees
Federal Tax ID #
Years in Business
Principal 1
Principal 1: Title
Principal 1: Email
Principal 2
Principal 2: Title
Principal 2: Email
	Current Equine Annual Premium
Farm AgriBusiness	$ Primary Carrier
Mortatlity	$ Primary Carrier
	Accounting Department
Contact Name
Phone
Email
	Customer Service Department
Contact Name
Phone
Email
E & O Coverage Carrier
E & O Policy Limit
E & O Deductible
E & O Policy Dates
Please include a copy of your P & C license, E & O declaration page and Certificate of E & O Insurance.
Name of Banking Facility
Bank Address
Bank Contact
Bank Phone
How Did You Hear About Equine World Insurance?
Your Name
Date