Agent Application

We welcome all established, professional Independent Pennsylvania Insurance Agents/Agencies to apply.  Just complete our Online Agent Application and a representative will be in touch with you.  Learn more about Becoming an Agent.

 

Agent Application
  1. Name(*)
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  2. Title
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  3. Company
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  4. Address 1:(*)
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  5. Address 2:
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  6. City(*)
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  7. State(*)
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  8. Zip Code(*)
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  9. Phone(*)
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  10. Fax
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  11. Email(*)
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  12. Profile Information


  13. Broker Volume
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  14. Commercial Volume
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  15. Workers Compensation Volume
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  16. Top 5 Commercial Carriers

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  17. Workers Comp Carriers

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  18. Need For Lackawanna Casualty Company

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  19. Marketing Activities


  20. # of Producers
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  21. Target Markets
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  22. Marketing Territory
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PA Compensation Rating Bureau

Commonwealth of Pennsylvania's Department of Labor & Industry

AMBest A-Rating

Occupational Safety & Health Administration (OSHA)

North American Industry Classification System (NAICS)

Dun & Bradstreet

Lackawanna Insurance Group

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