E&O Independent Agent Registration Form

Please fill out the following form. All elements are required unless otherwise noted.

Agency Name (name of insured)*:
*This must be the entity in contract with Allied or Harleysville.
Your main Nationwide Company affiliation:  Allied  
Mailing Address:

City, State Zip:
E&O Contact Name:
Phone Number:
Fax Number:
E-mail Address:
Last 4 digits of your SSN:
Last Year's E&O Premium (optional):
Current Policy Expiration Date: