IMPORTANT: When you click SUBMIT, you should receive a confirmation message. IF YOU DO NOT, you have missed a mandatory field. Look for the red text to see which field(s) are required, complete those fields, then click SUBMIT again. You application is successful when you receive a confirmation message after clicking SUBMIT.

* Required Fields
 Section 1:  About Your Agency
Person Completing Application 

First Name: 
*   
Last Name: 
*   
Daytime Telephone: 
*   
Email Address: 
*     
Agency Identification 

Agency Name: 
*   
DBA (if applicable): 
*   
In Business Since: 
*   
Number of Locations: 
Organization Type: 
*   
Tax ID (FEIN): 
Street Address 

Street Address 1: 
*   
Street Address 2: 
City: 
*   
State: 
  Note: At this time, GAINSCO is accepting applications for the states of AZ, FL, GA, NM, OK, SC, TN, TX, and VA only.
Zip Code: 
*   
Mailing Address 
(if different than street address) 

Mailing Address 1: 
Mailing Address 2: 
City: 
 
State: 
 
Zip Code: 
 
Agency Phone/Fax  

Main Phone Number: 
Main Fax Number: 
 Section 2:  Your Current Auto Insurance Carriers

 

Company Name

Annual volume

3-year loss ratio (%)

Years with this company

1.*


$ *

*

*

2.

$ *

*

*

3.

$*

*

*

4.

$*

*

*

5.

$*

*

*

 Section 3:  Agency Principals at Your Firm
 Please list all principals of your agency, including any officers and owners. For each Principla, be sure to check the check box next to each Principal completed. You are required to complete Principal 1.

 

First Name: 
*   
Last Name: 
*   
Title: 
*   
Email Address: 
*    
Home Address: 
*     
City: 
*   
State: 
*   
Zip Code: 
*   
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 Section 4:  Key Personnel at Your Firm
 Please list any additional key personnel at your firm, including managers, licensed agtents, and key contact personnel (lead CSRs, etc.). For each Employee, be sure to check the check box next to each Employee completed. You are required to complete Employee 1.

 

First Name: 
*   
Last Name: 
*   
Title: 
*   
Email Address: 
*   
Home Address: 
*   
City: 
*   
State: 
*   
Zip Code: 
*   
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 

First Name: 
Last Name: 
Title: 
Email Address: 
Home Address: 
City: 
State: 
Zip Code: 
 Section 5:  About Your Agents & Principals
Are the Agency Principals licensed Agents?  
Are the Agency Principals involved in the day-to-day operations?  
Is there a licensed Agent on the premises at all times during business hours?  
Does your agency have E&O coverage?  
Have any of the Agency’s Principals or Agents ever...

 

Been refused a surety bond?  

Been arrested, indicted, or convicted of a felony or misdemeanor, excluding minor traffic offenses?  

Been known by another name or conducted business in any other name?  

Been refused a license or had a license canceled in any state?  

Had an E&O claim?  

Declared bankruptcy?  
 Section 6:  General Questions

Number of nonstandard auto applications written per month?*

1 Month App:          6 Month App: 

Is the Agency a franchise?*

Majority of business is generated by:*

Comparative rating system(s) used:*







 


Major forms of advertising (check all that apply):*









Agency automation system used:

List any professional organization memberships or affiliations:

 Section 7:  Additional Agency Locations

Please list all additional office locations/licensees (other than the main location you listed on the previous page). You should include all locations currently using the same Federal Tax ID (FEIN). If multiple locations have different tax IDs, a separate agency application will be required per corporate identity.

If you do not have additional agency locations or licensees, check this box and continue on to Section 8:
 

If you do have additional agency locations, please fill out the fields below for each additional location.
Be sure to check the check box per additional location.

 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
 

Agency Name: 
License Number: 
Address 1: 
Address 2: 
City: 
State: 
Zip Code: 
   
 Section 8:  Acknowledgement

In making this application, it is understood that an investigative background report may be ordered. The Inquiry includes information as to your character, general reputation, and personal characteristics. You have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation. This form constitutes an application only, and does not guarantee appointment.

To acknowledge your acceptance of these terms, enter your initials and today’s date below, and click the “Submit” button to complete your application.

Enter your initials: 

*   

Today’s date: 

Month: * Day: * Year: *
     
 

   

IMPORTANT: When you click SUBMIT, you should receive a confirmation message. IF YOU DO NOT, you have missed a mandatory field. Look for the red text to see which field(s) are required, complete those fields, then click SUBMIT again. You application is successful when you receive a confirmation message after clicking SUBMIT.

   
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