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  • TSLA: Texas Surplus Lines Association, Inc. TSLA: Texas Surplus Lines Association, Inc.
    TSLA
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    TSLA
    Contact Information:
    TSLA
    Phone: 512.343.9058
    TSLA
    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:
    TSLA
    phone:
    512.343.9058
    TSLA
    TSLA
    TSLA
    fax:
    512.343.2896
    TSLA
    TSLA
    TSLA
    address:
    Great Hills Corporate Center
    9020-I Capital of TX Hwy N., Suite 370
    Austin, TX 78759
    TSLA
    TSLA
    TSLA
    email:
    jptsla@tsla.org
    TSLA
    information:
    Info Request Form
    TSLA
    TSLA
    TSLA
    TSLA

    TSLA Application for Voting Membership

    Online Registration

    TSLA

    To Complete This Application:

    1. All questions must be answered completely
    2. All information contained in this application will be held in strict confidence.
    3. Please provide the name of 3-5 current TSLA Voting members that we can contact about providing your firm with a sponsorship letter.
    4. Please include a $100 non-refundable application fee with your application. The association will bill you for the membership dues when application is accepted. Dues are prorated.
    5. Annual dues for Voting Membership are based on the size of your office as follows:
      1-10 employees
      11-30 employees
      31-50 employees
      51-75 employees
      76+ employees
       - $
       - $
       - $
       - $
       - $
      1000
      1400
      1700
      2100
      2500

    6. Failure to disclose material facts or misrepresentation contained in this application shall cause reason for automatic rejection or expulsion from TSLA.


    Assureguard EVSSL
    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
    This section must be completed in order to apply online
    Name of Applicant as shown
    on Surplus Lines License:
     
    Indicate Whether Your Firm Is:  

     

    If your firm is a sole proprietorship, name the owner; if a partnership, name the partners (including all classes of partners); if a corporation, name the officers and directors:
       
    How long has your firm been in business:  
    Please list address and telephone number(s)
    (including fax & email) of applicant's main office below:
    Phone #:     (800)#:
    Fax #:  
    Address:  
    City/State/Zip:  ,  
    Email Address:  
    Web Site Address:  
    If main office is outside of Texas, please list where branch offices are located (city) in Texas below:
    Please list complete address(es), phone and fax number(s)
    and contact name(s) of all branches in Texas below:
    Provide name and relationship of insurance related operations
    owned by or affiliate with Applicant or Principal Owner:
    Applicant's Surplus Lines License#:  
     (Please fax or mail a copy of license)
    List all licenses held by the applicant (identify type & license number):

     

    Detailed Information
    This section must be completed in order to apply online
    Please select if the applicant or any of the entities named above are members of the American Association of Managing General Agents (AAMGA) or the National Association of Professional Surplus Lines Offices (NAPSLO):
     
    List the name(s) of three insurance companies or MGA's used by the applicant for surplus lines placement:
    1.   2.   3.
    What is the applicants total annual premium volume based on the most current year for which figures are available?
     Total volume: $          Annual period: From: To:
    What percentage of the applicants total volume was written direct for insureds and what percentage was sub-produced through licensed agents?
     Direct: %     Sub-Produced: %
    Please list the name of your insurance carrier for your E&O, plus limit deductible and expiration date below
     E&O Insurance Carrier: 
     Limit Deductible: 
     Expiration Date: 
    During the last ten years, has the applicant or principal owner, officer/director or any business entity with which they were associated ever been refused a license by any insurance regulatory agency or authority?
     Yes   No     If "YES", please explain below:
     
    Has any such license ever been suspended, revoked, canceled or voluntarily surrendered?
     Yes   No     If "YES", please explain below:
     
    Has the applicant or principal owners ever held an insurance license under any other name(s)?
     Yes   No     If "YES", give name(s) below:
     
    Please give a biographical sketch below which describes all prior surplus lines experience of each individual who holds a Texas Surplus Lines license or who is an owner, an officer, or a director of the applicant who is directly responsible for the placement of surplus lines business:
     
    Has any policyholder ever suffered financial loss either in unpaid claims or losses or unpaid return premiums due to the placement of insurance to insolvent and/or unauthorized insurers by the applicant, or principal owners, officer or director of the applicant, or by any of the entities named above?
     Yes   No     If "YES", please explain below:
     
    Has the applicant, or any principal owner, officer or director, or any of the entities named above ever been an agent, a general agent, director, officer or an employee of an insurance company, managing general agency or surplus lines agent that has become insolvent, bankrupt, or had other serious financial problems?
     Yes   No     If "YES", please explain below:
     
    Has applicant or principal owner ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned for conviction of or plead guilty or nolo contendere to any information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud?
     Yes   No     If "YES", please explain below:
     
    Has applicant or principal owner ever been charged with a violation of any corporate securities statute or any insurance law, or has the applicant or principal owner been subject of any disciplinary proceedings of any federal or state regulatory agency?
     Yes   No     If "YES", please explain below:
     
    Has applicant or principal owner, or any associated business entity ever been placed under injunction, or restraining order of a court, or regulatory agency in respect to violation of any federal or state law relating to insurance securities?
     Yes   No     If "YES", please explain below:
     

     

    Submission / Credit Card Information
    1) Please provide name and email addresses for 3-5 current TSLA Voting Members that we can contact about providing us with letters of reference for your firm.
     
    TSLA Voting Member Name
    Email Address
    1.
    2.
    3.
    4.
    5.

    The undersigned hereby represents that all above statements are true and correct.

    2) Name of President, Managing Partner or Owner:   
    3) Your Name and Title:   
    4) Date:   
    5) Payment Method:
    Check
    (Invoice Me)
       Credit Card
    (Complete Section Below)
    6) Credit Card Information (A $100 non-refundable fee is required for this application submission):
    Credit card type:   
    Credit card #:   
    CVV / CVC Code:     What's This?
    Expiration date:   
    Name on card:   
    Credit card billing address 
    (Address / City, State Zip): 
      

     

    Additional Comments
    Please enter any additional comments in regards to your application.


    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.
    TSLA
    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.
    TSLA
          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
    Fax# (512) 343-2896

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