Wholesale Insurance Brokers, Health Insurance and Employee Benefits Providers - Client First Brokerage Services in Maryland

This form is your first step toward being able to sell online! Once we receive your information and required documentation, Client First will be able to enroll you in various online sales portals and valuable on‐line sales engines. These portals can be used stand alone by e‐mailing the web address or URL to your clients, or can be hosted on your website for easy access.

In order to complete your registration, we will need a copy of your
license in each jurisdiction and the declaration page for your E&O insurance.

Fax to 410‐583‐5464 or Email to web@clientfirst.com

ALL FIELDS ARE REQUIRED. Please note that missing information can cause delays.

Password

(Passwords must be 8‐20 characters long, mix of letters and non‐letters)

Agent Contact Information

Email Address

Full Name

Date of Birth

Agency Name

Street Address

City

State

Zip

Phone Number

Fax Number

Web Site

If you don't have a website of your own and
would like to start one, please check the box:

Insurance License Information Please fax or email a copy of your license in each jurisdiction.

Please select the markets you are
licensed and appointed to do business in: MD DC VA PA

E & O Policy Information Please fax or email a copy of the declaration page of your E&O Policy.

Carrier

Deductible

Policy #

Per Occurrence Max

Expiration Date

Aggregate Max