[E-Risk Services] - Register For The BAM On-Line Rating System

BAM RATING SYSTEM BROKER REGISTRATION

GENERAL BROKER INFORMATION:
Broker Name:

Broker Company Name:

Broker Mailing Address:

Broker State (abbreviated):

Telephone:	Fax Number:

E-mail Address:


CHECK THE OPTIONS BELOW THAT DESCRIBES YOUR COMPANY:
1. Broker Type:
Wholesale: Retail:
2. Coverages Written:
EPL: D&O: Fiduciary: Crime: E&O: Cyber Liability:
Upon review of the above information, E-Risk Services, LLC may, at our sole discretion, add your e-mail address to our database of registered BAM on-line rating system users. In the event your e-mail address is added to our system, enter that address in the Broker E-mail address line in the Broker Information box in our on-line BAM application form to receive quotes for any submissions.