Become Affiliated
To become affiliated, please complete and submit the forms listed below: For best results while using these fillable forms, the Free Adobe Acrobat Reader 9.0 is needed. Click on link located in the right column of this page to upgrade.

Fax, E-mail, or Mail the fully completed forms to:
The Potter Group, Inc, P.O. Box 650, Orchard Park, NY 14127-0650
Fax:  1-716-662-4723 or 1-716-662-4734
E-mail:  ejd@thepottergroup.com

If you have any questions, please call our office: 1-800-682-5049 x11

If you prefer to be contacted by one of our marketing representatives,
please complete and submit the form below.

First Name: Last Name:
Agency Name:
Street Address :
City:
State: Zip:
Telephone Fax *Telephone or Email Required
Email Address *Email or Telephone Required
Companies Currently Represented?
Where do you place your alternative business?
How long has your agency been in business? Years licensed?
Have you ever been disciplined by a governmental authority for an inappropriate use of an insured’s money?  Yes No
Have you ever been convicted of a felony?  Yes No
Have you ever had your insurance license suspended or revoked? Yes No



Copyright© The Potter Group, Inc. l P.O. Box 650 | Orchard Park, NY 14127-0650
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