Navigation

Skip to Content

Navigation Menu

Login

Navigation Menu

About Us Consumers Agents

Search

Agent Referral

Breadcrumb

fmap
Agent Referral

Form Runner

Your browser does not appear to support JavaScript. You may want to try one of the following:

Turn on JavaScript in your browser if it supports it.
Use a browser that supports JavaScript.
Try a JavaScript-free version of this page, if made available by the application author.

An error has occurred

You may want to try one of the following:

Close this dialog and continue to use this page.
Reload this page. Note that you will lose any unsaved changes.
If the above does not work, try reloading the page yourself. Note that you will lose any unsaved changes:
- With Firefox: hold down the shift key and click the Reload button in your browser toolbar.
- With Safari and Chrome: click the Reload button in your browser toolbar.
- With Internet Explorer: hold down the control key and click the Reload button in your browser toolbar.
Return home.

Reloading form

This form has to be reloaded. This most likely happened because your session has expired, which might take to the login page. (If you think that you shouldn't see this message and that the problem persists, please contact support.)

Help

$xforms-template-label$$xforms-template-help$$xforms-template-hint$$xforms-template-label$$xforms-template-help$$xforms-template-hint$

Agent Referral

You must resubmit this form every 12 months to remain on FMAP’s referral list for commercial residential, commercial nonresidential and liability insurance.

Date:

First name:First name required.

Last name:Last name required.

Agent license number:License number required.

Agency name:Agency name required.

Qualifying commercial carriers:Carriers required.

Email:Email required.

Re-enter email:Re-enter email.

Phone: Phone required.

Fax number:

Indicate all policy types you are able to write.

Commercial ResidentialApartments – WindApartments – X-windCondo association – WindCondo association – X-windHomeowners association – WindHomeowners association – X-wind

Commercial Nonresidential Property and Liability PropertyMini/strip mallsOffice buildingRestaurantsOther

LiabilityAircraft coverageAnimal liabilityBoatBuilding contractor - GLBusiness operationsChild day care business in homeEldercare provider with state contractElectric wheelchairs/scootersHull coverageLiabilityOther

Indicate all counties in which you are authorized to offer coverage with an admitted Florida carrier.All CountiesAlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSt. JohnsSt. LucieSanta RosaSarasotaSeminoleSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonSelection required.

By entering my initials below, I affirm that all information above is correct.Initials required.

5cd070fcd01c3727c2296e2af34f31a88c7db71c

Confirm

Form Submitted

Review Form Validation Messages

Unable to complete action

Confirmation

H2 Filler

Need to Contact Us?

Consumer Contacts

Consumer Contacts

Consumers, Need Help?

800.524.9023

Deaf/Hard-of-Hearing

800.955.8771 (TTY)
800.955.8770 (Voice)

Agents Resources and Contacts

Resources

Contact Us

General Inquiries
Agent Referral Form

Node: cit-ewas01:8080

Navigation Menu

Terms and Conditions | Privacy Policy | Contact Us | Admin Login

Copyright 2023 Florida Market Assistance Plan

Facebook Twitter