Please enter the General Agency Name.
Please only enter a single email address.
Select the states in which you would like to be appointed. Please provide
your license numbers for each respective state and attach a copy of the license.
Please also attach a copy of the deck page of your E & O coverage.
NOTE: A copy of your agent licensing (and agency if applicable) and E&O coverage
is REQUIRED complete your application. If you are unable to upload copies of these,
you may also email it to
or fax it to (651) 649-3502.
For the following questions, "you" refers to the individual or entity seeking to
be appointed with Combined Insurance Company of America.