Become a Broker with Blink

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Become a Broker with Blinkfotex2026-06-19T17:07:37+00:00

Become an Appointed Broker With Blink

Thank you for your interest in partnering with Blink Specialty Insurance Services. To be considered for appointment,
please download and complete the required documents below, then upload everything using the Appointment Application form.

Step 1: Download & Complete the Required Documents

Please download and fully complete the following items:

Completed and signed Producer Agreement
Fully completed Producer Appointment Questionnaire
Completed W-9 Form
Copies of licenses for all states you currently write business in
Copy of your E&O Declarations page

Please ensure all documents are completed and signed where required before uploading. Incomplete submissions may delay review.

Download Producer Questionnaire

Download W-9 Form

Download Broker’s Agreement

Step 2: Upload & Submit Your Application

Once your documents are ready, upload them using the Appointment Application form below.
Your submission will be emailed to our team for review, and we’ll reach out if anything additional is needed.

Appointment Application

Agency Name *

FEIN# *

DBA *

Address *

Address Line 1

City

State

Phone *

Email *

Website *

Accounting Contact Name

Accounting Email *

Accounting Phone Number

President / CEO Email Address *

President / CEO Cell Phone *

How many years has the entity been in business *

List all owners of the entity (partners, officers, etc)

Name *

Title *

Social Security # *

License #

Email Address

Cell Phone Number

Has any brokerage principal ever filed for bankruptcy? *

Provide a brief history of your Brokerage/Agency: *

date established, marketing efforts, branches, ets.

Has your Brokerage/Agency been a Plaintiff or Defendant within the last 5 years? *

Have you performed business under any other name? *

List all the Brokers, Solicitors, Producers, Sales Persons, etc., who are placing business through the Brokerage/ Agency

Name *

License # *

Years in Brokerage *

Years in Industry *

Speciality *

Provide names of the current Agencies and Insurance Carriers you place business with

Agency Name *

Ins. Company *

L.O.B. *

$ Volume

Loss Ratio *

Total volume placed through the Assigned (Pool) Plan?

Does your Brokerage/Agency specialize in any special L.O.B. or classes of business *

Percentage of the gross income that originates from these lines of business

Commercial Auto Liability *

Physical Damage *

Motor Truck Cargo *

General Liability *

Garage Dealers *

Other *

Does your Brokerage/Agency have more than one location?

Bank References

Contact Name *

Bank Name *

Trust Account # *

Routing Number *

Address *

Address Line 1

City

State

Attach Other Documents (signed broker agreement/E&O, W-9, state licenses)

Click or drag files to this area to upload. You can upload up to 10 files.