Get Appointed with Paragon

We are excited to work with you and are honored to earn your business. With our 25+ niche programs, we are ready to show you why specialty is our specialty.

To be appointed, you'll need to complete this form and provide:

- Agency Questionnaire

- W9 Form

- Current Errors & Omissions Declarations or Certificate

- Current Cyber Coverage Declarations, Certificate, or Endorsement

- Current Agency state license and individual producer license(s)

Important: Submitting this form is not considered a complete appointment. Your agency will be contacted at the information provided by you after a review of your submission. If approved, you will be sent an agreement to sign via PandaDocs to your compliance contact.

Agency Questionnaire

Legal Name

Cluster or Group Affilitation

DBA

FEIN

What type of agency?

What states do you market business in?

What Paragon Programs are you interested in?

Agency Total Annual Revenue

Why we ask this:
Cyber Liability dec page or certificate - Revenue Requirements:
• If the Total Annual Revenue is below $2,000,000 we require the agency to carry Cyber Liability with a minimum of a $250,000 aggregate
• If the Total Annual Revenue is between $2,000,000 and $3,000,000 we require the agency to carry Cyber Liability with a minimum of a $500,000 aggregate
• If the Total Annual Revenue is between $3,000,001 and $6,000,000 we require the agency carry Cyber Liability with a minimum of a $1,000,000 aggregate
• If the Total Annual Revenue is above $6,000,001 we require the agency to carry Cyber Liability with a minimum of a $2,000,000 aggregate
Paragon requires E&O insurance coverage with a minimum aggregate policy limit of $3,000,00

Mailing Address

Address (Cont)

Mailing City

Mailing State

Mailing Zip Code

Physical Address

Use Mailing Address

Physical Address

Physical Address (Cont)

Physical City

Physical State

Physical Zip Code

Marketing Contact

Marketing First Name

Marketing Last Name

Marketing Email

Accounting Contact

Accounting First Name

Accounting Last Name

Accounting Email

Compliance Contact

Compliance First Name

Compliance Last Name

Compliance Email

Get Appointed with Paragon

Agency Questionnaire

Mailing Address

Physical Address

Marketing Contact

Accounting Contact

Compliance Contact

Paragon Contact

Upload and Submit

W9

Agency & Producer Licenses

E&O Declarations or Certificate

Cyber Coverage Declarations, Certificate, Endorsement

Thank you for your time
and interest in working with
Paragon.

Get Appointed with Paragon

Agency Questionnaire

Mailing Address

Physical Address

Marketing Contact

Accounting Contact

Compliance Contact

Paragon Contact

Upload and Submit

W9

Agency & Producer Licenses

E&O Declarations or Certificate

Cyber Coverage Declarations, Certificate, Endorsement

Thank you for your time and interest in working with Paragon.

Thank you for your time
and interest in working with
Paragon.