New Agent - Broker Appointment Request for Residential Earthquake Insurance GeoVera specializes in providing standalone residential earthquake insurance. If you are interested in teaming up with GeoVera to offer these superior earthquake insurance products to your clients, simply complete the form below. Once your application for appointment has been approved, you will obtain access to: Quick Estimates in less than 30 seconds with GeoVera’s easy, instant earthquake insurance quoting website Online  payments for your earthquake insurance clients Online commission statements Online earthquake insurance policy inquiry

Note: The agency must have a valid insurance license for the state the product is offered in, and the license effective date must not be expired. If the application for appointment is approved, GeoVera will collect your licensing information at that time. Residential Earthquake Insurance   Available in California*, Oregon and Washington   *(not available in these California counties) Agency Name: Type of Business: Select Corporation Sole Proprietorship Other Year Established: Tax ID Number or SSN: Agency Contact Name: Job Title: Fax: Phone: Email: Mailing Address: City: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Is your Street Address the same as your Mailing Address? Street Address: City: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Marketing Area: List the City, State and/or County which is your main marketing area Top 3 Personal Lines Carriers: Average number of HO policies written per month: Anticipated monthly number of applications for GeoVera new business: Do you have a market you would like to move to GeoVera? Select Yes No If yes, provide Name of Carrier: If yes, estimated volume: