New Online User Registration

To request and gain full access to our entire LISI Web site, fill in and submit the requested information below.

As a registered user, valuable broker tools and services such as our online quoting system and materials, CE education program, forms and applications, plan information and many more, are available for your use and reference.

Please review our Privacy Policy for your reference.

* Required field entry.
LISI Broker Profile

*First Name:
Middle Initial:
*Last Name:
User Name:
Maximum of 60 characters
*  User Type:
 Unlicensed User (Assistant)     Not licensed by the Dept. of Insurance
 Independent Broker
 Broker working with Agency

Brokers applying for access are required to enter their license number. Unlicensed users are also required to provide either their agency’s or their associated broker’s license number. Please note, this number will appear on the cover page of all proposals as required by law.

* Broker License Number:
* Agency License Number:
*  License number on proposal cover page:
 Agent
 Agency
License Renewal Month:
License Renewal Year:
CE Credit(s):
DBA Name:Agency Name:
* Name on proposal cover page:
 Agent and Agency/DBA
 Agent Only
 Agency/DBA Only

* Agency Business Address:Affiliated Agency/Broker Business Address:
* Agency Name:Agency or Broker Name:
* Street:
* City:
* State:
* Zip:
-
* Agency Business Phone:

Please enter phone number in this format: nnn-nnn-nnnn.
Extension:
* Business Address:
* Street:
* City:
* State:
* Zip:
-

* Mailing Address:
Set From Business Address
* Street:
* City:
* State:
* Zip:
-

* Proposal Address:
Set From Business Address
* Street:
* City:
* State:
* Zip:
-

* Commission Address:
Set From Business Address
* Street:
* City:
* State:
* Zip:
-

* Supplies Address:
Set From Business Address
* Street:
* City:
* State:
* Zip:
-

Home Address:
Set From Business Address
Street:
City:
State:
Zip:
-

* E-mail:
*  Phone number on proposal cover page:
 Broker
 Agency

Please enter phone numbers in this format: nnn-nnn-nnnn.

* Business Phone:
Extension:
Direct Phone:
Extension:
Cellular Phone:
Extension:
Pager Phone:
Extension:
Toll-free Phone:
Extension:
Home Phone:
Extension:
Fax:
Extension:

 



 

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