ABOUT US

Become a Broker

Join the DeCotis group of dedicated retail agents that define our success by filling out the form below:

* Indicates a required field
* Agency Name	* Contact Person
* Mailing Address	* City
* State	* Zip
* Telephone Number	*Fax Number
* Email Address	* Years in Business
Type of Ownership
List the name(s) of the owner(s) of the agency.
1.* Owner's Full Name	Birthdate
2. Owner's Full Name	Birthdate
Key Agency Personnel
1. Full Name	Title/Position
	License Number
2. Full Name	Title/Position
	License Number
3. Full Name	Title/Position
	License Number
Annual Premium Volume * Total Volume All Lines $
* Do you maintain E&O Insurance? yes no
Has any company cancelled or refused to renew your E&O policy?
yes no If yes, why?

Has any company withdrawn from your agency in the past three years?
yes no If yes, give the name of the company and the reason.

I hereby declare that all statements made above are threi to the best of my knowledge.

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