Form MGA-1 (MO375-0019) "Managing General Agents (Mga) Appointment" - Missouri

What Is Form MGA-1 (MO375-0019)?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2019;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MGA-1 (MO375-0019) by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form MGA-1 (MO375-0019) "Managing General Agents (Mga) Appointment" - Missouri

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P.O. BOX 690
JEFFERSON CITY, MO 65102-0690
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
MANAGING GENERAL AGENTS (MGA) APPOINTMENT
FORM MGA-1
INSTRUCTIONS:
This appointment form is to be completed by an insurance company representative for each MGA they utilize.
Filing of this application does not give authority to your MGA. This authority does not exist until all required items are filed and a contract is
stamped “APPROVED” and returned to the insurer by this office.
This application must be accompanied by a $150.00 filing fee.
Please complete this form in full and submit with the required documents.
INSURER INFORMATION
NAME (FULL NAME OF INSURER)
HOME ADDRESS (STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS (STREET, CITY, STATE, ZIP CODE)
An MGA needs to be reported only if they manage all or part of the insurance business of an insurer and underwrites an amount of gross
direct written premium equal to or more than 5% of the policyholder surplus. If an insurer has more than one MGA that meets these guidelines,
a separate application must be completed for each.
MGA NAME
MGA LICENSE NO.
MGA TELEPHONE NO.
MGA ADDRESS (STREET, CITY, STATE, ZIP CODE)
CONTACT PERSON OF MGA
CONTACT PERSON OF INSURANCE COMPANY
THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH THIS APPLICATION FORM:
1. Original copy of fidelity bond in the amount of $100,000.
2. Copy of MGA’s errors and omissions policy.
3. Duplicate copy of the executed contract between the MGA and the insurer. The contract form to be used will be provided by this office.
APPROVAL OF AN INSURER AND THEIR MANAGING GENERAL AGENT (MGA) IS GRANTED BY THE MISSOURI DEPARTMENT OF
INSURANCE UPON RECEIPT BY THE INSURER OF AN “APPROVED” CONTRACT.
SIGNATURE
TITLE (PRINT OR TYPE)
MUST BE SIGNED IN
PRESENCE OF NOTARY
NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER SEAL
STATE OF
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 375-0019 (8-19)
EX
Save
Print
Reset
P.O. BOX 690
JEFFERSON CITY, MO 65102-0690
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
MANAGING GENERAL AGENTS (MGA) APPOINTMENT
FORM MGA-1
INSTRUCTIONS:
This appointment form is to be completed by an insurance company representative for each MGA they utilize.
Filing of this application does not give authority to your MGA. This authority does not exist until all required items are filed and a contract is
stamped “APPROVED” and returned to the insurer by this office.
This application must be accompanied by a $150.00 filing fee.
Please complete this form in full and submit with the required documents.
INSURER INFORMATION
NAME (FULL NAME OF INSURER)
HOME ADDRESS (STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS (STREET, CITY, STATE, ZIP CODE)
An MGA needs to be reported only if they manage all or part of the insurance business of an insurer and underwrites an amount of gross
direct written premium equal to or more than 5% of the policyholder surplus. If an insurer has more than one MGA that meets these guidelines,
a separate application must be completed for each.
MGA NAME
MGA LICENSE NO.
MGA TELEPHONE NO.
MGA ADDRESS (STREET, CITY, STATE, ZIP CODE)
CONTACT PERSON OF MGA
CONTACT PERSON OF INSURANCE COMPANY
THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH THIS APPLICATION FORM:
1. Original copy of fidelity bond in the amount of $100,000.
2. Copy of MGA’s errors and omissions policy.
3. Duplicate copy of the executed contract between the MGA and the insurer. The contract form to be used will be provided by this office.
APPROVAL OF AN INSURER AND THEIR MANAGING GENERAL AGENT (MGA) IS GRANTED BY THE MISSOURI DEPARTMENT OF
INSURANCE UPON RECEIPT BY THE INSURER OF AN “APPROVED” CONTRACT.
SIGNATURE
TITLE (PRINT OR TYPE)
MUST BE SIGNED IN
PRESENCE OF NOTARY
NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER SEAL
STATE OF
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 375-0019 (8-19)
EX