Coronavirus (COVID-19) Information REGISTER LOGIN Become an agent Please be aware that agencies who want to represent Eastern Alliance must go through a highly selective appointment process. We are looking to partner with mid-size to large agencies who share our belief in offering clear service differentiation. As a result, we limit the number of appointments available in each geographical region based upon current market penetration. The questionnaire below is the first step in determining the suitability of an agency appointment. A marketing representative from your region will review your submitted questionnaire and contact you regarding the status of your request. Thank you for your interest! Prospective Agent Contact Us Form Please Complete the form below and click the Submit button. Required fields are indicated with a red asterisk * General Agency Information Name Email Agency Name Year Agency Established Mailing Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Main Location Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Other Location Addresses Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Office Phone Office Fax Agency Website Address What state(s) is/are your Agency Licensed in? Select all AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Business Focus (%): Commercial Benefits Investments Number of Employees Commercial Department Number of Producers Commercial Department Commercial Lines Strategy Total Commercial Volume and Total Workers' Compensation Volume Commercial WC Top 3 Workers' Compensation Carriers Name Year Appointed Premium Vol Loss Ratio Name Year Appointed Premium Vol Loss Ratio Name Year Appointed Premium Vol Loss Ratio Top 3 Package Carriers Name Year Appointed Premium Vol Loss Ratio Name Year Appointed Premium Vol Loss Ratio Name Year Appointed Premium Vol Loss Ratio Target Classes/Niches/Areas of Focus Retention Strategy New Business Development Strategy Strategy for Hiring/Developing/Retaining Producers Average Account Size Targeted 0-20K 20-100K 100K + Size Targeted Average Agency Retention Rate Agency Competitors What state(s) are you Targeting for Workers' Compensation Production? Select all AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Once you click "Submit," you should see a confirmation screen. If you do not receive a response to this questionnaire within 7 business days, please contact us at 1.855.533.3444. Submit Cancel Report A Claim 24/7 1-800-336-3658 Contact Eastern 1-855-533-3444 IN TW SOLUTIONS Traditional Loss Sensitive Specialty Risk unite Inova N3L3 ecovery RESOURCES Workers' Comp 101 Prevent Fraud FAQ Resource Library Posting Notices News & Events Safety Tools Payment Solutions ProAssurance Family THE EASTERN WAY At A Glance How We Serve You Mission, Vision & Core Values Leadership Team Social Responsibility Diversity, Equity, and Inclusion eaport GET IN TOUCH Join Our Team Find An Agent Become An Agent Contact Us Careers Report a Claim Copyright 2021 Report an Ethics Concern Privacy Policy/Legal Statements Terms & Conditions HIPAA & Eastern NY Residents Sitemap