top of page
Asset 2_300x.png

Agent Profile

Thank you for your interest in becoming an Agent Partner with Amelia Underwriters. Please complete the following information so one of our Account Representatives can get back to you. The asterisk(*) indicates a required field.

General Information
Are you licensed in multiple states?
Tax ID Information
Attach W9 Form
E&O Information
Attach E&O Forms
ACH Information

For commissions and return premium only.

Attach Voided Check
Contact Information
Principal Agent

Please add each agent (up to 3) that needs access to the system, including the principal agent.

Attach Copy of License
Second Agent
Attach Copy of License
Third Agent
Attach Copy of License

By typing your name below, you agree to our terms and conditions.


bottom of page