Welcome Agent

Thank you for your interest in becoming an appointed agent partner with E Golomb Insurance Services, Inc. We need to get some information from you to get the process started. Questions marked with * are required to submit the form.

General Information

Agency Users

We often work with many individuals within a single agency. Based on your business operation you may have multiple contacts should you need to. For example, controller, accountant, CSR, etc.. Please note that the first contact person has the agency administration permissions.

Insurance Information

Signature and Certification

Finally, we’ll ask you to sign the form, certifying that the information you just provided is correct.