Payments and Forms

Make a Payment

Payments are handled securely through third party platforms. Making a payment does not bind, change, or cancel insurance coverage.

Make an Advisory Payment

Make a Strong Tower Payment

Make an Advisory Payment

Make a Strong Tower Payment

Submit a Request or Application

Use the options below to submit an insurance request or apply for a wholesale appointment. Each option will open the appropriate form.

Request Commercial Insurance

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- Step 1 of 5

Note: A separate workbook will be required for all coverage placement requests.

How Did You Hear About Us? *

Business/Organization Name *

DBA (if applicable)

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FEIN *

Year Established *

Primary Contact *

Title *

Email *

Phone *

Mailing Address *

Address Line 1

City

State

Zip Code

Services Requested *

Advisory
Business Insurance
Church Insurance
Non-Profit Insurance

Industry Classification (Select One) *

Churches and Faith-Based Organizations
Non-Profits
Construction
Manufacturing
Banking/Financial Institutions
Real Estate (Including agents and brokers)
Healthcare
Technology
Barbershops/Personal Care
Consultants
Transportation

Description of Operations *

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Annual Revenue *

No. of Employees *

Website

Coverage Requested *

General Liability
Property
Business Owners Policy (BOP)
Workers’ Compensation
Commercial Auto
Umbrella / Excess Liability
Cyber Liability
Professional Liability (E&O)
D&O / EPLI / Fiduciary
Crime / Fidelity
Other

Other *

Request Personal Insurance

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Applicant Information - Step 1 of 7

Named Insured (Primary) *

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Date of Birth (DOB) *

SSN (last 4) *

Additional Named Insured

Relationship/Entity Type *

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Email *

Mobile *

Mailing Address *

Address Line 1

City

State

Zip Code

Is Physical Address same? *

Physical Address (if different) *

Address Line 1

City

State

Zip Code

Preferred Contact Method *

Preferred Contact Method
Email
Text

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Best Time to Reach *

Marital Status *

Single
Married
Other

Occupation/Employer *

Household Members (Adults & Licensed Teen Drivers) *

Check all that apply *

Auto (Personal)
Homeowners (HO-5)
Condo (HO-6)
Renters (HO-4)
Umbrella/Excess
Personal Articles Floater
Flood (NFIP/Private)
Boat/Watercraft
Motorcycle/ATV
Dwelling Fire (DP)
Mobile/Manufactured Home
Classic Auto
RV
Short-Term Rental
Other

Other *

Current Carrier(s) *

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Policy no. *

Exp. Date *

Years Continuous Coverage *

Any lapse in past 5 years?

If Yes, Explain *

Prior Liability Limits (Auto / Umbrella / Home) *

Any losses in the last five (5) years? *

Insurance carriers may obtain your official loss history from reporting databases or prior insurers. Failure to disclose all losses within the past five (5) years may be considered a material misrepresentation and could affect eligibility, pricing, or the ability to offer coverage. Please answer accurately and completely

Loss History (5 years)

Date *

Line *

Cause *

At Fault? *

Paid / Reserve Amount *

Status *

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Vehicle Year *

Make/Model *

VIN *

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Garaging ZIP *

Use *

Commute
Pleasure

Miles per Year *

Comp / Coll *

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Driver Name *

DOB *

Driver License Number / State *

Years Licensed *

Violations? (3yrs) *

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SR-22 *

Marital Status *

Single
Married

Rideshare / Delivery *

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Platform *

Frequency *

Property Address *

Address Line 1

City

State

Zip Code

Occupancy *

Primary
Secondary
Rental

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Year Built *

Square Feet *

Stories *

Property Build *

Frame
Masonry
Joint Masonry
Non-Combustible
Modified or Semi-Fire Resistive
Fire Resistive

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Roof Type / Year *

Heating Type *

Updates *

Update Year *

Protection *

Smoke
CO
Sprinkler

Alarm (Central) *

Distance to Hydrant (ft) *

Distance to Fire Station(miles) *

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Pool *

Trampoline *

Dogs / Breeds *

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Solid Fuel Burner *

Short-Term Rental *

Any prior claims at this location? *

Property Claim Details

Date *

Line *

Cause *

At Fault? (copy) *

Paid / Reserve Amount *

Status *

Auto Liability (BI / PD) *

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UM / UIM *

MedPay / PIP *

Rental/Towing *

Home Coverage

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Coverage A (Dwelling) *

Coverage B *

Coverage C *

Loss of Use (D) *

Liability (E) *

MedPay (F) *

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Deductible *

Wind / Hail Deductible *

Are you requesting an Umbrella? *

Disclaimer: Umbrella coverages are subject to underlying limits determined by the carrier. If underlying falls below required limits, carrier may deny umbrella.

Do you have any high value items to add? (i.e. Jewelry, art work, instruments, etc.)

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Signed & dated application *

Click or drag a file to this area to upload.

Prior declarations pages (all lines) *

Click or drag files to this area to upload.You can upload up to 5 files.

Appraisals (if scheduled items)

Click or drag files to this area to upload.You can upload up to 5 files.

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Photos (property exterior / scheduled items)

Click or drag files to this area to upload.You can upload up to 5 files.

Proof of updates (roof/electrical/plumbing/HVAC)

Click or drag files to this area to upload.You can upload up to 5 files.

Driver's licenses and MVR consent

Click or drag files to this area to upload.You can upload up to 5 files.

Flood elevation certificate (if applicable)

Click or drag a file to this area to upload.

Apply for Wholesale Appointment

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Agency Information - Step 1 of 7

Legal Agency Name *

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DBA (if applicable)

EIN *

Physical Address *

Is Physical Address Same as Mailing Address? *

Mailing Address *

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Website *

Phone *

Fax

General Email *

Principal #1:

Name *

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Title *

Ownership *

Principal #2:

Name *

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Title *

Ownership *

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Principal Agents NPN *

Parent Company (if any)

Year Established *

States Licensed To Operate *

Agency License Number(s) *

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Resident State

Non-Resident States *

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E&O Carrier Name *

E&O Policy Number *

E&O Limits ($1M minimum Aggregate limit) *

E&O Expiration Date *

Primary Lines of Business Written (P&C, Personal, Commercial, Specialty) *

Current Wholesale Relationships *

Approximate Annual Premium Volume *

Target Classes for STS Placement (E&S) *

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Number of Employees *

Sub-Producer Model? *

Accounting Contact *

Claims Contact *

Does your agency accept fees? *

Does your agency accept fees? If yes, describe: *

Describe your agency’s compliance procedures *

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Agency License(s) *

Click or drag a file to this area to upload.

E&O Declarations Page *

Click or drag a file to this area to upload.

W-9 Form *

Click or drag a file to this area to upload.

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Sample Client Agreement

Click or drag a file to this area to upload.

Anti-Fraud Statement *

Click or drag a file to this area to upload.

Authorized Signer Name *

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Title *

Date *

I hereby certify that the information provided is true and complete to the best of my knowledge. *

I hereby certify that the information provided is true and complete to the best of my knowledge.

If you have any questions or issues with the process, please contact our Agency Appointments Team at agencyappointments@strongtowerusa.com.

Payments and Forms

Make a Payment

Submit a Request or Application

Loss History (5 years)

Property Claim Details

Home Coverage

Principal #1:

Principal #2:

Quick Links

Legal & Compliance