Prospective Agent Data Collection

Thank you for expressing your interest in becoming an agent for Boundless Rider. This is the first step of the onboarding process. Here we will collect basic information about you and your producer license(s) information. We will then review this information and, if everything is in order, we will send you on to the next step which is collecting your relevant tax, insurance, and agent profile information. After we confirm that information we will prepare and send you any necessary documents for execution.

If you have any questions or you are having any issues completing this form, please reach out to a member of our Agent Support Team either by email or by phone at 800-814-7231.
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Email *
Agent First Name *
Agent Middle Name
Agent Last Name
 *
License Number of Resident State *
Agent Resident License state abbreviation
 *
NPN *
Agent Business Phone Number *
Agent Business Mailing Address *
In which states are you seeking an appointment? State abbreviations should be used (DE, CT, TX, AZ, etc.). Type NA if not applicable.
 *
I hereby confirm by my signature (as indicated by me typing my name below) that my resident and non-resident (if applicable) producer license(s) are active. *
Will the producer documents be in your name or in the name of an agency?
Note: If producer documents will be signed in an agency name, you will be sent a separate questionnaire to complete after we review this form. *
If an agency is involved, are you the principal agent of the agency? Type NA if not applicable. *
If you are not the principal agent, please type in the name and email address of the principal agent. Type NA if not applicable. 
**Note, if you are not the principal agent, we will need to contact them and get the agency information before moving you onto the Boundless Rider platform.
 *
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This form was created inside of Boundless Rider.