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Agency Appointment Form

Please complete and submit this form to the LIPCA marketing department at your earliest convenience. Our marketing department will contact you very shortly.

As a Lloyd's of London Coverholder for its Pest Control General Liability program, LIPCA can serve you as you serve your pest control clients.

LIPCA offers to agents:

  1. A superior GL product that includes coverage for all phases of pest control work.
  2. In-house services that range from quick quoting turnaround, online policy and certificate servicing and a seasoned and specialized staff that know pest control and its insurance needs, and includes an in-house claims staff totally dedicated to your pest control clients' claims handling.
  3. A generous commission schedule!

We appreciate your inquiry and look forward to working with you soon.

 


Agency Name:
Mailing Address:
City:
State:
Zip:
Physical Address:

(If different from Mailing Address)

City:
State:
Zip:
Web Site Address:
Producer / Principle Contact Name:
Producer / Principle Phone Number:
Producer / Principle Email Address:
Accounting Contact Name:
Accounting Phone Number:
Accounting Email Address:
Fax Number:
General Correspondence Email Address (if any):
FEIN/SSN:
Type of Business: Corporation  
Partnership  
Sole Proprietorship  
LLC  
NPD Agency Number (if any):
Resident State Agency License Number:

Surplus Lines License Holder?

 Yes  
No  
States in Which You and/or Your Agency Are Licensed (including Surplus Lines):

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Current Company/MGA Appointments for Pest Control General Liability (if any): 1.
2.
3.
Current Value of Pest Control General Liability Book of Business:

State(s) in Which You are Interested in Writing Pest Control General Liability Business:

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Errors & Omissions Carrier:
Limits of Liability:
Expiration/Renewal Date:
E & O Claims History (if any):
 

Please fax proof of your agency’s Errors and Omissions coverage and a copy of the agency’s P&C license to the attention of Andy McGinty, COO, at 225-927-3295.

This agent appointment request is not to be construed as a fully-executed Producer Agreement between the above-listed agency and LIPCA, Inc., and does not confer any rights or responsibilities contained therein.  A Producer Agreement must be signed and fully executed prior to any request for binding by the above-listed agency.

 

Please contact me as soon as possible regarding agency appointment, the pest control industry or your available programs.

Please send a Producer’s Agreement to me at the contact name and information provided above as soon as possible.