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Agent Referral

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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.

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