Producer Agreement Form

To secure a quote from ZAS, a producer agreement is required. By completing the information requested below, a producer agreement will be on file with ZAS. Upon submission of this information, you will receive a confirmation e-mail and have the opportunity to begin submitting new business.

Download a Copy of the Producer Agreement

General Information

Authorized Signer:*

Signer Title:*

Email:*

Phone:*

Agency License Number:*

E&O Carrier:*

Upload a Copy of Your Agency License:

Upload Proof of E&O Insurance:*

Main Product Interest:

Agreement Effective Date:*

Business Information

Legal Producer Name:*

Business / DBA Name:*

Business Address:*

City:*

State:*

ZIP Code:*

State of Organization:*

Organization Type:* Sole ProprietorPartnershipCorporationOther

Federal EIN:*

By checking this box and signing below, I agree that I am submitting valid information and electronically signing the Producer Agreement.

Zurich Agency Services, Inc.

Producer Agreement Form

Producer Agreement Form

General Information

Business Information

Applicant's Signature