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Please fill out all applicable fields below.

* Indicates Required Field

Applicant Information

First Name*

Last Name*

Agency Information

Agency Name*

Street Address*

City*

State*

ZIP Code*

Phone Number*

Example: 8005551212

Email Address*

Example: name@domain.com

Confirm Email Address*

Example: name@domain.com

Agency Website URL*

Example: www.yourcompany.com

Agency Background*

Start-upFormer captive/exclusive, new to IA channel and exp in the insurance industryModerate tenure in IA channel (3-4 years) and new to SafecoMature, long-tenured in IA channel (5+ years) and new to SafecoModerate tenure in IA channel (3-4 years) and previously appointedMature, long-tenured in IA channel (5+ years) and previously appointed

Former Captive Company*

All StateFarmersState FarmAlliedLiberty MutualNationwideOther

Are you free and clear of your contract?*

YesNo

When will you be free and clear of your contract?*

Please enter valid information.

Start-up Experience*

New to IA channel and inexperienced in the insurance industryNew to IA channel (less than 5 years)Experienced in IA Channel (greater than 5 years)

Are you currently appointed with Safeco Insurance or Liberty Mutual Insurance?*

YesNo

Have you been appointed with Safeco Insurance or Liberty Mutual Insurance at any point in the past?*

YesNo

How long since last appointment?*

Less than 1 year1-3 Years3+ years

Years in Business*

Less than 6 months6 months - 1 year1 - 3 yearsMore than 3 years

Personal Lines Written Premium*

Less than $100k$100 - $1million$1million - $5millionMore than $5million

Total Written Premium*

Less than $100k$100 - $1millionMore than $5million

Top 3 Personal Lines Markets (Companies)

1.Company*Please enter only alphanumeric charactersWritten Premium*Please enter only numeric characters

2.Company (optional)Please enter only alphanumeric charactersWritten Premium (optional)Please enter only numeric characters

3.Company (optional)Please enter only alphanumeric charactersWritten Premium (optional)Please enter only numeric characters

How many total Personal Lines carriers do you write business for?*

0 - 34 - 1010 - 15More than 15

Message (optional)

Please enter a Message that contains only alphanumeric characters, apostrophes, hypens, periods, commas, and question marks

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Insurance is offered by Safeco Insurance Company of America and/or its affiliates, with their principal place of business at 175 Berkeley Street, Boston, Massachusetts, 02116. This website provides a simplified description of coverage. Nothing stated herein creates a contract. All statements made are subject to the provisions, exclusions, conditions and limitations of the applicable insurance policy. Please refer to actual policy forms for complete details regarding the coverage discussed. If the information in these materials conflicts with the policy language that it describes, the policy language prevails. Coverages and features not available in all states. Eligibility is subject to meeting applicable underwriting criteria.

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