Carrier Membership Membership Selection * Carrier - $ 10,000.00 Total Amount Carrier Company Details To ensure your application submits correctly, please avoid pasting any text with formatting (such as bold, italics, or special fonts). We recommend copying text only from plain text documents like Notepad, which removes any unwanted formatting. General Information Company Name * Main Contact Email * Street Address * City * State * - select State/Province - Aberdeen City Aberdeenshire Aguascalientes Alabama Alaska Alberta American Samoa Angus Antrim and Newtownabbey Ards and North Down Argyll and Bute Arizona Arkansas Armagh City, Banbridge and Craigavon Armed Forces Americas Armed Forces Europe Armed Forces Pacific Baden-Württemberg Baja California Baja California Sur Baker Island Bayern Bedfordshire Belfast Berkshire Berlin Blaenau Gwent Brandenburg Bremen Bridgend Bristol, City of British Columbia Buckinghamshire Caerphilly California Cambridgeshire Campeche Cardiff Carlow Carmarthenshire Causeway Coast and Glens Cavan Ceredigion Cheshire Chiapas Chihuahua City of Hamilton Clackmannanshire Clare Clwyd Co Antrim Co Armagh Co Down Co Fermanagh Co Londonderry Co Tyrone Coahuila Colima Colorado Connecticut Conwy Cork Cornwall County Durham Cumbria Delaware Denbighshire Derbyshire Derry City and Strabane Devon Devonshire District of Columbia Distrito Federal Donegal Dorset Dublin Dumfries and Galloway Dundee City Durango Dyfed East Ayrshire East Dunbartonshire East Lothian East Renfrewshire East Riding of Yorkshire East Sussex Edinburgh, City of Essex Falkirk Fermanagh and Omagh Fife Flintshire Florida Galway Georgia Glasgow City Gloucestershire Greater Manchester Guam Guanajuato Guerrero Gwent Gwynedd HaDarom Haifa Hamburg HaMerkaz Hamilton Parish Hampshire Hawaii HaZafon Herefordshire Hertfordshire Hessen Hidalgo Highland Howland Island Idaho Illinois Indiana Inverclyde Iowa Isle of Anglesey Isle of Wight Jalisco Jarvis Island Jerusalem Johnston Atoll Kansas Kent Kentucky Kerry Kildare Kilkenny Kingman Reef Lancashire Laois Leicestershire Leitrim Limerick Lincolnshire Lisburn and Castlereagh London Longford Louisiana Louth Maine Manitoba Maryland Massachusetts Mayo Meath Mecklenburg-Vorpommern Merseyside Merthyr Tydfil Mexico Michigan Michoacin Mid and East Antrim Mid Glamorgan Mid Ulster Midlothian Midway Islands Minnesota Mississippi Missouri Monaghan Monmouthshire Montana Moray Morelos Na h-Eileanan Siar Navassa Island Nayarit Neath Port Talbot Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador Newport Newry, Mourne and Down Niedersachsen Nordrhein-Westfalen Norfolk North Ayrshire North Carolina North Dakota North Lanarkshire North Yorkshire Northamptonshire Northern Mariana Islands Northumberland Northwest Territories Nottinghamshire Nova Scotia Nuevo Leon Nunavut Oaxaca Offaly Ohio Oklahoma Oldham Omagh Ontario Oregon Orkney Islands Oxfordshire Paget Palmyra Atoll Pembroke Pembrokeshire Pennsylvania Perth and Kinross Powys Prince Edward Island Puebla Puerto Rico Quebec Queretaro Quintana Roo Renfrewshire Rheinland-Pfalz Rhode Island Rhondda, Cynon, Taff Roscommon Rutland Saarland Sachsen Sachsen-Anhalt Saint George's San Luis Potosi Sandys Saskatchewan Schleswig-Holstein Scottish Borders Shetland Islands Shropshire Sinaloa Sligo Smiths Somerset Sonora South Ayrshire South Carolina South Dakota South Glamorgan South Gloucestershire South Lanarkshire South Yorkshire Southampton Staffordshire Stirling Suffolk Surrey Swansea Tabasco Tamaulipas Tel-Aviv Tennessee Texas Thüringen Tipperary Tlaxcala Torfaen Town of St. George Tyne and Wear United States Minor Outlying Islands Utah Vale of Glamorgan, The Veracruz Vermont Virgin Islands Virginia Wake Island Warwick Warwickshire Washington Waterford West Dunbartonshire West Glamorgan West Lothian West Midlands West Sussex West Virginia West Yorkshire Westmeath Wexford Wicklow Wiltshire Wisconsin Worcestershire Wrexham Wyoming Yucatan Yukon Territory Zacatecas Zip * Company Website * Please list any insurance companies with whom you are affiliated Does your company grant binding/underwriting authority (delegated underwriting authority) to program administrators? Yes No Please describe in detail the authority granted to program administrators AM Best Rating How many years has the company been in program business? How many program administrators do you work with? Total Number of Programs 2-5 6-10 11-25 26-50 51-100 100+ Do you offer Fronting options? None Pure Hybrid Both Paper Status Offerings AdmittedNon-AdmittedBoth Minimum annual written premium considered Consideration of start-up programs Yes No Required 1st Year Minimum Premium Do you have a carrier rating system available or is this an expectation of your program administrator? Yes No Both Do you provide claims handling or is this an expectation of the program administrator or an independent TPA? Yes No Both Do you provide loss control services? YesNoSometimes Information About Program Business Strategy and Risk Appetites Programs your company is most interested in pursuing (lawyers, contractors, etc.)? Accident and Health Accountants Actuarial Consultants Agency and Association Captives Agent insurance and real estate Agricultural Related Business Aircraft Airport Allied Health Amusement parks and rides Apartments Appraisers Architects and Engineers Armored Cars Artisan Contractors Asbestos & Lead Abatement Assisted Living Associations Attorneys Auctions and farmers markets Auto and truck dealers Auto Dealer Automobile Auto Physical Damage Auto Products Auto Services Aviation Bail/Immigration Bonds Bankers Banks and financial institutions Bars and Taverns Beaty Salons Beauty Salons Behavioral Health Boat/Yachts Boat and recreation dealers including marinas Boiler/Equipment Breakdown Bond Programs BOP Breweries and wineries Brownwater Hull Brown water Hull Builders Risk Camps Canine Care Providers Cargo Casinos CAT Coverage Chemical and Petroleum Chiropractors Clubs golf Clubs other than golf Coastal Property Coastal Wind Commercial Automobile Community Associations Community Service Associations Condominiums and Apartments Construction Construction Wrap Up Consultants Contractors artisan Contractors Crane and rigging Contractors demolition Contractors electrical Contractors elevator Contractors energy Contractors environmental Contractors Equipment Contractors excavation Contractors general Contractors HVAC Contractors infrastructure Contractors janitorial Contractors residential construction Contractors solar Contractors sprinkler including alarm Contractors wrap up Correctional Cosmetics/Tattoo/Body Piercing Crane & Rigging Credit Guarantee Credit Insurance Crime Cultural Institutions Cyber Coverage Data Breach Dealers Open Lot Dentists Dry cleaning and laundry Earthquake Electrical Contractor Electronic Equipment Emergency Transport Energy Engineers Entertainment Centers Environmental EPLI Equine Equipment Floaters/Breakdown Event Events Extended Warrantee Farming and livestock operations Farming Operations Fidelity and Crime Fiduciary Liability Film Financial Institution Fine Arts Firearm sales including manufacturing Fire Sprinkler/Alarm Fitness Centers Food Services Forest Products Gaming Garage Dealer & Service General Contractors Golf Grocery Stores Habitational Hazardous Products Healthcare High Value Property Historic Sites Home Builders Home Health/Staffing Home Inspectors Hospitality Hotel/Motel Installation Insurance Agents Intellectual Property Jewelers Block Labor Professional Landscapers Laundry Law Practices Lease and Loan Services Logging Maintenance Services Management Liability Manufactured Housing Manufacturing Marinas Marine and Hull Liability Medical Devices/Facilities Medi Spas Mental Health Midwives Mining Misc E&O Mobile Home Park Mortgage Brokers Motorsports Motor Truck Cargo Moving and Storage Municipalities Musical Instruments Network Security Night Clubs/Adult Entertainment Non-Coastal Property Non Emergency Medical Transportation Non Profits Non Subscription Nuclear Energy Nurses Nursing Homes Parking Garage PEO Operations Personal Umbrella Pest Control Pet Pet Care Pharmaceutical Manufacturing Physicians Physicians/Surgeons Playground Equipment Installers/manufacturers Podiatrists Pollution Private Investigators/Security Professional Liability Property Property Management Psychiatrists Public Entity Public Transportation Pyrotechnics Railroad risks Real Estate Agents/Appraisers Religious Institutions Rental Business Repossession/Towing Residential Care Facilities Restaurants Restaurants all other Restaurants franchise Retail stores Roofing Schools Schools - Other Schools - Private Schools - Public Security Guards Self-Storage Senior Living Short Tail Business Social Services Solar Sporting Clubs Staffing Business Storage Tank Structural Engineers Taxi/Livery Technology & Media Temporary Staffing Terrorism Title Agents Tool/Instrument Towing and repossession Trade and Foreign Credit Trucking USL&H Utilities Utilities energy Utilities water and sewer Vacant Building Valet Warranty Weather Wildlife Wind Wineries Zoo contractor - plant ATM/Storage Unit Cannabis Which lines of business your company is most interested in? Accident and Health Aggregate Stop Loss Association Captive Auto Liability Auto Physical Damage Automobile Bail bonds Bid bonds BOP Builders Risk Business Income Casualty Coastal Property Commercial Bonding Construction bonding Court bonds Credit Guarantee Crime Crime & Fidelity Crop Cyber Risk D&O Data breach Dealers Open Lot DIC Disability Earthquake Environmental Environmental/Pollution EPLI Equipment Breakdown Equipment Floaters/Breakdown Excess Liability / Umbrella Fidelity and Crime Fiduciary Liability Fiduciary Surety bonds Flood Flood Insurance Foreign Liability General Liability Health Homeowners Identity Theft Immigration bonds Industry Captive Inland Marine Jewelers Block Kidnap/Ransom License and Permit Surety Bonds Life Management Liability Marina Operators Legal Liability Marine and Hull Liability Maritime Employers Liability Media Liability Medical Professional Liability Medicare Supplement Misc E&O Motor Truck Cargo Motorcycle/ATV/Snowmobile Non Standard Auto Non Subscription Non-Trucking Liability Ocean Marine Package Payment bonds Performance bonds Personal Umbrella Professional Liability Property PropertyCAT PropertyCAT - Earthquake PropertyCAT - Flood PropertyCAT - Hail PropertyCAT - Hurricane PropertyCAT - Wind Protected Cell Company Protection and Indemnity Public Official Surety bonds Railroad Liability Rent-a-Captive Short Tail Business Single Parent Captive Site Improvement bonds Subdivision bonds Supply bonds Tax Credit Terrorism Travel and Accident Umbrella and Excess Liability Umbrella Liability Umbrella/Excess Liability USL&H Warranty Workers Compensation Workplace Violence Programs your company will NOT consider Accident and Health Accountants Actuarial Consultants Agency and Association Captives Agent insurance and real estate Agricultural Related Business Aircraft Airport Allied Health Amusement parks and rides Apartments Appraisers Architects and Engineers Armored Cars Artisan Contractors Asbestos & Lead Abatement Assisted Living Associations Attorneys Auctions and farmers markets Auto and truck dealers Auto Dealer Automobile Auto Physical Damage Auto Products Auto Services Aviation Bail/Immigration Bonds Bankers Banks and financial institutions Bars and Taverns Beaty Salons Beauty Salons Behavioral Health Boat/Yachts Boat and recreation dealers including marinas Boiler/Equipment Breakdown Bond Programs BOP Breweries and wineries Brownwater Hull Brown water Hull Builders Risk Camps Canine Care Providers Cargo Casinos CAT Coverage Chemical and Petroleum Chiropractors Clubs golf Clubs other than golf Coastal Property Coastal Wind Commercial Automobile Community Associations Community Service Associations Condominiums and Apartments Construction Construction Wrap Up Consultants Contractors artisan Contractors Crane and rigging Contractors demolition Contractors electrical Contractors elevator Contractors energy Contractors environmental Contractors Equipment Contractors excavation Contractors general Contractors HVAC Contractors infrastructure Contractors janitorial Contractors residential construction Contractors solar Contractors sprinkler including alarm Contractors wrap up Correctional Cosmetics/Tattoo/Body Piercing Crane & Rigging Credit Guarantee Credit Insurance Crime Cultural Institutions Cyber Coverage Data Breach Dealers Open Lot Dentists Dry cleaning and laundry Earthquake Electrical Contractor Electronic Equipment Emergency Transport Energy Engineers Entertainment Centers Environmental EPLI Equine Equipment Floaters/Breakdown Event Events Extended Warrantee Farming and livestock operations Farming Operations Fidelity and Crime Fiduciary Liability Film Financial Institution Fine Arts Firearm sales including manufacturing Fire Sprinkler/Alarm Fitness Centers Food Services Forest Products Gaming Garage Dealer & Service General Contractors Golf Grocery Stores Habitational Hazardous Products Healthcare High Value Property Historic Sites Home Builders Home Health/Staffing Home Inspectors Hospitality Hotel/Motel Installation Insurance Agents Intellectual Property Jewelers Block Labor Professional Landscapers Laundry Law Practices Lease and Loan Services Logging Maintenance Services Management Liability Manufactured Housing Manufacturing Marinas Marine and Hull Liability Medical Devices/Facilities Medi Spas Mental Health Midwives Mining Misc E&O Mobile Home Park Mortgage Brokers Motorsports Motor Truck Cargo Moving and Storage Municipalities Musical Instruments Network Security Night Clubs/Adult Entertainment Non-Coastal Property Non Emergency Medical Transportation Non Profits Non Subscription Nuclear Energy Nurses Nursing Homes Parking Garage PEO Operations Personal Umbrella Pest Control Pet Pet Care Pharmaceutical Manufacturing Physicians Physicians/Surgeons Playground Equipment Installers/manufacturers Podiatrists Pollution Private Investigators/Security Professional Liability Property Property Management Psychiatrists Public Entity Public Transportation Pyrotechnics Railroad risks Real Estate Agents/Appraisers Religious Institutions Rental Business Repossession/Towing Residential Care Facilities Restaurants Restaurants all other Restaurants franchise Retail stores Roofing Schools Schools - Other Schools - Private Schools - Public Security Guards Self-Storage Senior Living Short Tail Business Social Services Solar Sporting Clubs Staffing Business Storage Tank Structural Engineers Taxi/Livery Technology & Media Temporary Staffing Terrorism Title Agents Tool/Instrument Towing and repossession Trade and Foreign Credit Trucking USL&H Utilities Utilities energy Utilities water and sewer Vacant Building Valet Warranty Weather Wildlife Wind Wineries Zoo contractor - plant ATM/Storage Unit Cannabis Lines of business your company will NOT consider Accident and Health Aggregate Stop Loss Association Captive Auto Liability Auto Physical Damage Automobile Bail bonds Bid bonds BOP Builders Risk Business Income Casualty Coastal Property Commercial Bonding Construction bonding Court bonds Credit Guarantee Crime Crime & Fidelity Crop Cyber Risk D&O Data breach Dealers Open Lot DIC Disability Earthquake Environmental Environmental/Pollution EPLI Equipment Breakdown Equipment Floaters/Breakdown Excess Liability / Umbrella Fidelity and Crime Fiduciary Liability Fiduciary Surety bonds Flood Flood Insurance Foreign Liability General Liability Health Homeowners Identity Theft Immigration bonds Industry Captive Inland Marine Jewelers Block Kidnap/Ransom License and Permit Surety Bonds Life Management Liability Marina Operators Legal Liability Marine and Hull Liability Maritime Employers Liability Media Liability Medical Professional Liability Medicare Supplement Misc E&O Motor Truck Cargo Motorcycle/ATV/Snowmobile Non Standard Auto Non Subscription Non-Trucking Liability Ocean Marine Package Payment bonds Performance bonds Personal Umbrella Professional Liability Property PropertyCAT PropertyCAT - Earthquake PropertyCAT - Flood PropertyCAT - Hail PropertyCAT - Hurricane PropertyCAT - Wind Protected Cell Company Protection and Indemnity Public Official Surety bonds Railroad Liability Rent-a-Captive Short Tail Business Single Parent Captive Site Improvement bonds Subdivision bonds Supply bonds Tax Credit Terrorism Travel and Accident Umbrella and Excess Liability Umbrella Liability Umbrella/Excess Liability USL&H Warranty Workers Compensation Workplace Violence Other program considerations/submission criteria Complete description of your program review/evaluation process including time frame for completion Existing Programs Check the states in which you are NOT licensed to write on Admitted Paper (primary carrier and other insurance companies) Alaska Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Check the states in which you are NOT licensed to write on Excess and Surplus paper (non-admitted primary carrier and other insurance companies) Alaska Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please provide an overview of the 3 most significant programs you currently underwrite. Program 1 1: Administered by 1: Product Lines 1: Approximate GWP Program 2 2: Administered by 2: Product Lines 2: Approximate GWP Program 3 3: Administered by 3: Product Lines 3: Approximate GWP References Please provide two written references – preferably from current TMPAA program administrators. Reference letters should contain the following elements: Confirmation that the PA has binding and underwriting authority for your program Brief description of the PA’s experience developing, implementing, and maintaining a program with your company Support of your company’s membership in the TMPAA to work with other PA members Reference 1 1: Name 1: Company 1: Phone 1: Email Reference 2 2: Name 2: Company 2: Phone 2: Email Email reference letters to gene.abbey@targetmkts.com. Additional Comments/Questions Additional Comments/Questions I understand that the application must be favorably considered by the membership committee before the applicant can participate in the Association. An invoice for the non-refundable membership fee will be sent after approval. By submitting this application: The applicant attests that all information in the application is correct. The applicant will abide by the Association Bylaws as they may be amended from time to time. The applicant is not aware of any reason why the Bylaws cannot be observed. The applicant agrees to comply with the TMPAA Code of Conduct. Account Please enter a Username to create an account. If you already have an account please login before completing this form. Username * Check Availability Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores. Password Confirm Password Provide a password for the new account in both fields. Primary Contact First Name * Last Name * Email * Payment Options [x] Payment due upon approval Review your contribution Additional Individuals Actively Participating in the Association First Name Last Name Email 1 2 3 4 5