New Broker Questionnaire

Name on Texas Surplus Lines license

DBA name (trade name(s) approved by TDI)

Surplus Lines license number

License expiration date

Employer size
---1-1011-5051-100100+

Agency type
---Managing General AgentWholesale BrokerIndividual Broker

Contact Information

Primary SLTX Contact Name

Email Address

Phone Number

Alternate Phone Number

Agency/Broker website address

What is the correct address for your agency/broker? Please provide physical and P.O. Box, if you use both.

Physical Address

P.O. Box

As a default, we will use the P.O. Box. However, larger packages will be sent to the physical address.