Please fill out the New Agent/Broker Application provided below. Fields marked with an asterisk (*) are required. You will also need to forward the following documents to our New Gloucester, Maine office. Click the following link for the full address Northeast Branch Offices

  1. E&O Declarations Page
  2. ISR Producer Agreement

New Agent/Broker Application
Fields marked with an asterisk (*) are required.
Agency Name*:
  
Contact Name*:
 Position:
Address 1*:
  
Address 2
 City*:
 State*:
 Zip*:
Phone*:
 Fax*:
E mail*:
 Web Page
State License Number:
 Expiration Date:
Federal Tax ID Number:
  
E&O Carrier Policy Number:
 Expiration Date:
Limits of Liability:
 Expiration Date:
Please advise which Insurance Companies you currently place your marine business with by type of business.
Type of Business:

Company:
If you need a printed copy of this application, please use your browser's print button before you submit this form.
PLEASE CLICK TO SUBMIT THIS APPLICATION:

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Questions / Comments? Contact us at info@isr-insurance.com
50 Salem Street, Building B, 3rd Floor, Lynnfield, MA 01940
Phone: 781-295-0270 Fax: 781-246-7830