GAINSCO Auto Insurance® Car Insurance Agent Application

Contact Info for Person Completing the Application

Please tell us a little about you.

Name*

First Last

Agency Name:*

DBA (if applicable):

Phone Number*

Your Email Address*

Your Title

What is your primary role at the agency?

Are you someone at the agency who rates and binds policies?*

Yes
No

Have you previously worked at an agency who writes GAINSCO?*

Yes
No

Agency Information

Agency Website

Street Address*

Address Line 2

City*

State*

Zip Code*

Please enter 5 digit zip code

Is your current location open for business?*

Yes
No

Been in business since:

Please enter year only

Does your location have a storefront?

Yes
No

How does your agency conduct the majority of its business?*

Retail_Office_Only
Call Center Only
Call Center and Retail

Does your business have multiple locations?*

Yes
No

Please indicate the total number of locations.

Type "1" if you only have one location.

Are you or someone at your agency licensed to sell insurance?*

Yes
No

Does your agency have E&O coverage?*

Yes
No

Tell Us About Your Agency's Business

Is your agency willing to write state minimum limit personal auto insurance policies?*

GAINSCO specializes in state minimum limits personal auto insurance.

Yes
No

How many state minimum limit auto applications does your agency write per month on average?

In which state do you currently write personal auto insurance business?*

List auto insurance carriers with whom you currently do business:

Please only list company names

Which comparative rating system does your agency use?

Do you use an agency management system?

Yes
No

Has your agency been appointed previously with GAINSCO?

Yes
No

How did you hear about GAINSCO?

Acknowledgement

In submitting this form, I agree to opt-in to operational and marketing communications from GAINSCO Auto Insurance. This form constitutes interest only and does not guarantee appointment. In addition, you may receive a request for more information before the appointment process can begin. To acknowledge your acceptance of these terms, enter your initials and today’s date below, and click the “Submit” button to complete your prospect interest form.

Enter your initials:

Date

Email

This field is for validation purposes and should be left unchanged.

Prospect Application for Agency Appointment

Contact Info for Person Completing the Application

Agency Information

Tell Us About Your Agency's Business

Acknowledgement

Customers

Agents

Answers

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