Cowbell Agency Registration Form

Agency Information

* indicates required fields
Agency Name*
As you would like displayed to policyholders
Legal Name
If different from Agency Name
Main Physical Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Number of Agency Office Locations*
Agency FEIN*
Agency NPN*
Retail or Wholesale?*

RetailWholesale
Preferred Billing*

Agency BillDirect Bill
Commercial P&C Premium Volume*
Number of P&C Producers*

Top 3 Specialties/Niches*

	Specialty/Niche	% of Book
#1
#2
#3

Cyber Premium Volume*
Number of Cyber focused Producers/Employees*
Current Cyber Policy Count*
Projected Cyber Policy Count in 12 Months*

Top 3 Cyber Markets*

	Market/Carrier	% of Book
#1
#2
#3

Does your agency have E&O Insurance?*

YesNo
Does your agency have Cyber Insurance?*

YesNo