Broker Profile
To receive an agent kit and more information on how you can partner with Cove Risk Services, please complete the broker profile below. We have requested this information so we can better understand who we are doing business with and how we can best provide the products and services available.
*Required Field
Name of Agency*
Contact Person*
Address*
City*
State*
Zip Code*
Phone*
Fax
Web Address
Email
Agency Premium Size*
($)
Personal Lines*
(%)
Commercial Lines*
(%)
Total Number of Employees*
Number of Salespeople*
Number of Office Locations*
Principal(s)*
Year Established*
Agency Tax ID Number*
***Required Form: W-9***
(To become an active broker with Cove Risk, you MUST download, complete, sign and return this form to Cove Risk Services, Attention: Broker Sales, 35 Braintree Hill Office Park, Suite 206, Braintree, MA 02184.)
How did you hear about Cove Risk Services?
For what industry(ies) are you interested in workers' compensation coverage?
AutomotiveContractingEducationHospitalityManufacturingRestaurantRetailTransportation
Do you specialize in any area/field or vocation?*
YesNo
If yes, which one(s)?
Who are your top three (3) Commercial Carriers for workers' compensation?*
Commercial Carrier 1
Commercial Carrier 2
Commercial Carrier 3
Your Name*
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