Insurance CE

Insurance Pre-Licensing

Contact Information:

Phone: 512.343.9058

Thank you for visiting TSLA, a non-profit, trade association of excess and surplus lines brokerage and underwriting professionals. If you would like more information about our association and membership benefits, please contact us at your convenience:

phone:
512.343.9058

address:
Great Hills Corporate Center
9020-I Capital of TX Hwy N., Suite 370
Austin, TX 78759

email:
jptsla@tsla.org

information:
Info Request Form

TSLA Application for Affiliate Membership

Online Registration

Applicable questions must be answered. The information developed by this questionnaire is required by the association's bylaws and is kept in confidence. Submission of this application does not constitute automatic acceptance of membership.

To Complete This Application:

All questions must be answered completely.
All information contained in this application will be held in strict confidence.
Please remember to include a sponsorship letter from a TSLA Voting member. List of Voting members may be found on our website at www.tsla.org.
Please include a $50 non-refundable application fee with your application. The association will bill you for the membership dues when application is accepted. Dues are prorated.
Annual dues for Affiliate Membership are $1100.
Failure to disclose material facts or misrepresentation contained in this application shall cause reason for automatic rejection or expulsion from TSLA.

This Online Application is on a Secure
Server. Click on the seal on the left
for more information on the
certificate's authentication.

Please complete the sections below:

General Information
Name of Applicant firm:
Address:
City:	State: Zip:

Contact Information
Provide name(s) of person(s) whom mail should be directed and listed as firm contact:
Name:
Title:
Address:
City/State/Zip:
Phone:	Fax:
Email:

2nd Contact (Name):
Title:
Address:
City/State/Zip:
Phone:	Fax:
Email:

Branch Information
Provide complete address, phone and fax number(s) and contact name for all branches in Texas (if any):
Contact Name:
Address:
City/State/Zip:
Phone:	Fax:
Email:

Second Contact (Name):
Address:
City/State/Zip:
Phone:	Fax:
Email:

Detailed Information
Is your firm approved to do business in the state of Texas as a Surplus Lines Insurance Company?	Yes No Not Applicable
Texas Company Number:
TDI Eligibility Date:
Indicate whether your firm is:	Surplus lines insurance company Licensed/admitted insurance company Reinsurance company Lloyd's of London Syndicate Managing General Underwriter

List all Associations of which you are a Member:


Please indicate your latest A.M. Best Rating (if applicable):

Briefly describe the types of coverages/classes of business you are currently underwriting:


Provide list of any specialties or Programs you are currently underwriting:


During the past ten (10) years, have you or any business entity with which you were associated ever been refused a license by any public or governmental licensing agency or regulatory authority?
Yes No If yes, please provide details:

Has your firm or any member of your firm had a license refused, revoked or suspended?
Yes No If yes, please provide details:

Has your firm or any other business entity with which you have been associated been convicted and/or sentenced for any misdemeanor or felony involving theft, larceny, fraud, charging a violation of any corporate securities statute or any other insurance laws?
Yes No If yes, please provide details:

Submission Information
1) Please fax or mail a letter of sponsorship from a Voting TSLA member.

2) Name of President, Managing Partner or Owner:

3) Your Name and Title:

4) Date:

Payment Information
Please Note: *A $50 non-refundable* fee is required for this application submission.**
Amount Due:	$
Payment Method:	Invoice Me (remit check) eCheck (ACH/eCheck) Credit Card

Additional Comments

Please enter any additional comments in regards to this online submission.

Please check the box below and then press the Submit button to send your application to TSLA. Please review your information for accuracy before submitting this form. TSLA is not responsible for any incorrect information entered into this form.

You must check the box below in order to submit your registration:

I agree to allow TSLA to bill my credit card (if applicable) and have reviewed all info I have provided for accuracy.

PLEASE NOTE: If you would rather fax or send your application via regular mail, please use the Print Application button below and then fax or mail to the number or address listed below.

and / or

If you would like to fax or mail your registration form, please fax or mail to:

Texas Surplus Lines Assn., Inc.
9020-I Capital of Texas Hwy N. #370
Austin, Texas 78759

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