We are very excited to help build a book of business together at Direct Insurance Services! Please complete the following form with accompanying items to make sure we have you set up correctly and quickly.

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About You

Your Name(Required)

First Last

Email(Required)

Cell Phone Number(Required)

List states where you conduct business:(Required)

Business Type(Required)

Business EIN(Required)

EIN Documentation

Max. file size: 12 MB.

Business Name(Required)

Desired Business Name - We set up your LLC

Business Address Setup(Required)

I have an address I want to use

Please use Registered Agent (Direct Insurance Services will set up)

Business Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Social Security Number(Required)

Emergency Contact Person(Required)

Emergency Contact Relationship(Required)

Emergency Contact Email(Required)

Emergency Contact Phone Number(Required)

Authorization(Required)

I agree to give Direct Insurance Services, my consent and permission to set up my partnership. All findings will remain private and confidential with you and Direct Insurance Services LLC.

Signature(Required)

By signing my name on form below, I agree this as a signature to this form.

Any Additional Comments/Questions

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New Partnership Information Sign Up – Brokers Are Better

Next Steps: Sync an Email Add-On

About You

Direct Insurance Services

Social Media

Get a Quote

Navigation

For Clients

Surrounding Areas Served in Colorado

Log In

Don’t have an account?

Start Your Quote

Select an Insurance Type

Personal
Insurance

Business
Insurance

New Partnership Information Sign Up – Brokers Are Better

Next Steps: Sync an Email Add-On

About You

Direct Insurance Services

Social Media

Get a Quote

Navigation

For Clients

Surrounding Areas Served in Colorado

Log In

Don’t have an account?

Start Your Quote

Select an Insurance Type

Personal Insurance

Business Insurance

Personal
Insurance

Business
Insurance