Date of Request

Agency Information

Name

Name of Agency

Street Address

City

State

Zip

Phone

pomi offers group accident coverage only. Please select the business category(ies) below in which you plan to sell/currently sell the most group accident coverage.

K-12 Schools
Camps
Non Profits
Health and Fitness
Colleges and Universities
After School Activities
Childcare Centers
Youth Sports
Other... This choice will expand a text box

Are you currently licensed to sell group accident insurance? If you are not currently licensed, appointments will be delayed until a license is obtained.

Enter your License Number here

Please list the state(s) where you need to be appointed. NOTE: We currently cannot write in the state of New Hampshire.

Proud partner of

Agency Information

Main Office

Corporate office

General inquiries

Tech support

Broker relations

Claims

Underwriting

Marketing & Communications