Agency code:

Agency legal name:

Agency address:

City

State

Zip code

Producer name:

First name:

Middle name:

Last name:

Suffix

Agency FEIN#:

Your NPN#:

Date of birth:

Producer email address:

Producer phone:

Producer home address:

Physical street address

City

State

Zip code

If a FL non-resident license is held, will you be physically entering the state to write business? Yes No

If yes, in what counties will you be physically soliciting business? (If no, enter N/A)

Are you authorized to have access to online commission reports? Yes No

I hereby certify all of the information herein is accurate and complete and any falsification, misrepresentation or omission of information from this form may result in withholding or withdrawal of any state appointment by Markel Service, Incorporated for its affiliated insurance companies. Any fines or penalties resulting will be the responsibility of the applicant.

You consent and agree that your affirmative selection of the below button on this electronic form constitutes your signature, acceptance and agreement as if actually signed by you in writing.

Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature.

Admitted Insurance products and services written or provided by subsidiaries and affiliates of Markel Corp. including, but not limited to: Markel Services, Inc.; Markel Insurance Company; Markel American Insurance Company; FirstComp Insurance Company, SureTec Insurance Company, SurTec Indemnity Insurance Company, and Essentia Insurance Company.

Individual producer appointment application

This form is applicable for all Markel affiliated Admitted Insurance Companies.

An appointment with the applicable state insurance department will not be made with one or more of the Markel affiliated Admitted companies until an account has been solicited with that company, unless state law requires otherwise.

By completing this form you agree to make us aware if you need an appointment before any account solicitation.

Producer name:

Producer home address:

Applicant individual background questions

If you responded yes to any of the individual background questions, please explain all in detail under separate cover and attach appropriate documents (I.e. official court records, etc.), and email to agencyappointment@markel.com.

Individual producer appointment application