Become an Agent FollowFollowFollow Become an Agent Step 1 of 4 25% Agency Name* Name First Last Title Address* Street Address City State / Province / Region ZIP / Postal Code Email* PhoneWebsite Are you currently placing business through an Aggregator, Cluster or Network? Yes No If Yes, please list. Are you currently appointed with a partner carrier of Palomar? Yes No If Yes, please identify and provide your agency code. Does your firm have multiple locations?* Yes No How many years has your firm been in business?* Does your organization identify as a minority owned business? Yes No Prefer not to Answer What type of minority group does your business identify with? Check all that apply African American Asian American American Indian / Alaska Native Hispanic or Latino Middle Eastern American Native Hawaiian / Pacific Islander LGBTQ+ Veteran Woman Person with Disabilities Prefer not to Answer What PL products are you interested in? Earthquake Flood Hawaii Hurricane Specialty Homeowner's Other What CL products are you interested in? DIC/Earthquake Flood Inland Marine General Casualty Other Total Premium Volume: $Total Premium Volume CL: $Total Premium Volume PL: $CAPTCHA
