Become a PSIC Producer:
Thank you for your interest in becoming a producer for Pacific Specialty insurance products.
( * Required fields)

E Mail and Identifiers:
Office E-mail Address *
State *
Insurance Producer
Partner Affiliation *
Partner Affiliation Code

License information
License Type: *
Name as shown on license *
Corporate Name/DBA Approved by DOI
License Number
License Expiration Date / / *
Copy of License
The application cannot be processed until we receive a copy of your License.
 
Tax information:
SSN ex: xxx-xx-xxxx
Tax ID ex: xx-xxxxxxx *
Physical Office Location (PO Box not acceptable)
Address *
City, State, Zip *
Phone - - *
Fax - - *
Mailing Address (PO Box acceptable)
Address Same as Location Address.
City, State, Zip
Personal Lines Contact Information
First Name
Last Name
Commercial Lines Contact Information
First Name
Last Name
Principal's Information
First Name *
Last Name *
Home Address *
City, State, Zip *
Home Phone - - *
Home Fax - -
Date of Birth / / *
Errors & Omissions Policy Information
E&O Company *
E&O Amount *
E&O Policy *
Effective Date / / *
Expiration Date / / *
E&O Policy
Broker Bond Information
Do you have a Broker Bond  Yes    No *
Electronic Transfer Authorization Agreement
Do you want to use an EFT Account  Yes    No *
Onboarding Documents
If not all documents are attached, your onboarding process will be delayed until we get all documentation. We require a license or licenses and E&O from all producers as well as a broker bond in California producers. We will contact you as to any documents still needed.