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Brokers

Lancet continues to enjoy significant growth as we continue to build strong relationships with our broker network.  At the same time we look forward to stablishing new relationships with brokers who would like to work with Lancet.  Lancet understands that without the strong and loyal support of its broker network it would be much more difficult to sustain its growth .In this regard, should you like to find more about our programs and the ease of working with us then please read the following Broker / Agency Agreement.  If interested in moving forward, fill out the form below and attach a copy of your license(s) and the signed Broker / Agency Agreement.

 

Broker Information Form

Please fill out our Broker Information Form below.

Broker Name

Agency Name

Owners/Principals


Main Office Address

Phone

Email

Fax


Mailing Address (if different)


Office Manager

Phone

Email


Accounting Manager

Phone

Email


Administrative Assistant

Phone

Email


In which states are you licensed and writing business

Years in business

Total professional/medical liability book of business

What companies do you represent in the medical liability business


E and O carrier currently

Amount of coverage (Coverage at least 1M/3M

Effective Date

Expiration Date


Please provide a copy of your license(s)