Get Appointed

Complete Our Agent & Broker Appointment Process Online

Your clients deserve the best coverage at the most competitive prices. At VGM Insurance, you get all of that and more, because we know there’s more to insurance than finding the best rate. From the flexibility we offer, to our dedication to only working with the highest-rated carriers, you can trust us with what matters most to your insureds. Complete the form below to begin our agent and broker appointment process, and our team will be in touch with you for any additional information, and to finalize the agreement. If you have questions in the meantime, please reach out to us at services@vgminsurance.com or 800-362-3363.

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Agency Profile

* - Indicates required fields

Agency Name*

Website

Date Agency Established

Physical Address

Address*

City*

State*

ZIP*

Phone*

Fax

FEIN Number*

Mailing Address

Address*

City*

State*

ZIP*

Branch Office – Complete for additional locations if applicable

Physical Address

Address

City

State

ZIP

Phone

Fax

Mailing Address

Address

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ZIP

Branch Office #2

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Branch Office #3

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Branch Office #4

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Branch Office #5

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Branch Office #6

Physical Address

Address

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Address

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ZIP

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Billing/Accounting Information

Contact Name*

Email*

Phone*

Fax

Mailing Address

Address*

City

State

ZIP

Agency Ownership

Name of Individual or Entity*

Ownership %*

Add Another

Key Personnel

Name*

Title or Duties*

Phone*

Email*

Add Another

Signer Information

Name*

Title*

Email*

Additional information to add to form

Additional Required Documentation

Current License(s) For All States

Current E&O Policy Declaration Page

Note: All agents and brokers appointed with VGM Insurance must have at least $1M E&O coverage limits

Completed & Signed Copy of Current IRS Form W-9

I consent to having VGM Insurance collect my information. *

* By clicking this button, I hereby authorize VGM Insurance to call me on the residential or wireless telephone number I provided and participate in email communication as necessary, regarding the intent of this form submission. I also understand that my email might be used for future product promotions and that I can opt out of future communications from VGM Insurance at any time. Check out our privacy policy for more information about how we protect and manage your data.