I am an existing:

BrokerCustomer

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• Forgot Password or Username?
• What's my username?

Note: This section is for new HSA brokers ONLY. If you are already a broker with HSA Insurance, you already have an assigned user ID and password. To obtain this information, press “Forgot Password” and you will be notified by email. This will ensure that all of your information is located in one file.

(Note: Fields in bold are required fields. Also, please only enter letters and numbers. No symbols.)

General Information

Producer's Name (first,mi,last):

Referred By:

Business Name:

Business Address (Line 1 & 2):

City, State, Zip:

Phone:

Ext:

Fax:

Email:

Confirm Email:

License, Credentials and Liability

License State:

Renewal Date (mm/dd/yyyy):

Other License States (use spaces between states, no commas):

Industry Credentials:

Additional Qualification Info:

Errors and Omissions

E O Carrier:

Renewal Date (mm/dd/yyyy):

Liability Limits Per Claim:
(No Commas or Periods)

Liability Limits Per Year:
(No Commas or Periods)

Policy Reviewed Date:

Policy Name Of:

Requirements for Temporary ID

I agree that I am a licensed broker in the states in which I am quoting. I agree that I have the necessary Errors and Omissions insurance for both myself and if I am associated with a brokerage, that the brokerage has the necessary coverage. Upon writing a policy with HSA, I will return the necessary paperwork, including W9 forms and proof of insurance coverage in a timely fashion. I understand that I will use this temporary ID only until HSA has issued me an internal ID