Agency Producer Application

Fill out the form as completely and accurately as possible and click 'Submit' to forward the request to the FWCJUA. We will review the application to ensure all required information is present and accurate. Once the verification is complete, the completed application will be emailed to the Contact Email for signatures.
 If you have any questions in regard to what type of information a particular field is looking for, hover over the field with your mouse for additional information.

  Agency / Primary Location Details

To complete the Agency Producer Agreement including Exhibits A & B, enter the required information in the Agency Detail section by typing data into each field then pressing the tab key to move to the next field.
Once completed click on the Next  button to add additional Agency Locations.
   Agent-In-Charge information is needed for administrative purposes. If the agent needs to be authorized, be sure to add them to the location when you are in the Producer section.

  Please remember to email and attach the Agency's E & O Certificate of Insurance noted on the initial screen to agency@fwcjua.com .