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3.160.150.24  Public Scan

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URL: https://agents.nextinsurance.com/appointment?serial=992856554&channel=InsuranceJournal&source=InsuranceJournal&prev_tracking_id=2...
Submission: On November 20 via api from UA — Scanned from PL

Form analysis 1 forms found in the DOM

<form _ngcontent-ng-c989955601="" novalidate="" class="appointment-form ng-untouched ng-pristine ng-invalid">
  <div _ngcontent-ng-c989955601="" class="row-collapse">
    <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Principal Legal First Name </label><input _ngcontent-ng-c989955601="" type="text" formcontrolname="firstName" data-test="first-name"
        class="ng-untouched ng-pristine ng-invalid"></div>
    <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Principal Legal Last Name </label><input _ngcontent-ng-c989955601="" type="text" formcontrolname="lastName" data-test="last-name"
        class="ng-untouched ng-pristine ng-invalid"></div>
  </div>
  <div _ngcontent-ng-c989955601="" class="row-collapse">
    <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Principal Email Address </label><input _ngcontent-ng-c989955601="" id="GTM-event-email-input" type="email" formcontrolname="email" data-test="email"
        class="ng-untouched ng-pristine ng-invalid"></div>
    <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Phone Number</label><input _ngcontent-ng-c989955601="" id="GTM-event-phone-input" type="tel" formcontrolname="phone" data-test="phone"
        class="ng-untouched ng-pristine ng-invalid"></div>
  </div>
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label">Agency Type</label><ng-select _ngcontent-ng-c989955601="" formcontrolname="organizationType" bindvalue="value" data-test="organization-type"
      class="form-dropdown ng-select-searchable ng-select-clearable ng-select ng-select-single ng-untouched ng-pristine ng-invalid">
      <div class="ng-select-container">
        <div class="ng-value-container">
          <div class="ng-placeholder">Select type</div><!----><!---->
          <div role="combobox" aria-haspopup="listbox" class="ng-input" aria-expanded="false"><input aria-autocomplete="list" type="text" autocorrect="off" autocapitalize="off" autocomplete="a3260b7d5078"></div>
        </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
      </div><!---->
    </ng-select></div>
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Agency Website </label><input _ngcontent-ng-c989955601="" type="text" formcontrolname="agencyWebsite" data-test="agency-website"
      class="fs-unmask ng-untouched ng-pristine ng-invalid"></div><!---->
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> Principal Agent National Producer Number
      <i _ngcontent-ng-c989955601="" tooltipposition="top" tooltipstyleclass="appointment-tooltip" hidedelay="2500" class="p-element pi pi-question-circle"></i><!----></label><input _ngcontent-ng-c989955601="" type="text"
      formcontrolname="principalAgentNpn" data-test="principal-agent-npn" class="ng-untouched ng-pristine ng-invalid"></div>
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> What is your agency’s total written premium? </label><input _ngcontent-ng-c989955601="" type="text" formcontrolname="totalWrittenPremium"
      data-test="total-written-premium" placeholder="Annual Written Premium ($)" class="ng-untouched ng-pristine ng-invalid"></div>
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> What percentage is Commercial premium? </label><input _ngcontent-ng-c989955601="" type="text" formcontrolname="commercialPremiumPercentage"
      data-test="commercial-premium-percentage" placeholder="%" class="ng-untouched ng-pristine ng-invalid" pattern="[0-9]*"></div>
  <div _ngcontent-ng-c989955601="" class="row"><label _ngcontent-ng-c989955601="" class="label"> What percentage is Small Business? (Accounts less than $25k) </label><input _ngcontent-ng-c989955601="" type="text"
      formcontrolname="smallBusinessPercentage" data-test="small-business-percentage" placeholder="%" class="ng-untouched ng-pristine ng-invalid" pattern="[0-9]*"></div><ni-button _ngcontent-ng-c989955601="" id="in-take-submit"
    data-test="submit-button" _nghost-ng-c840608666=""><button _ngcontent-ng-c840608666="" class="ni-button" disabled="">Submit <!----><!----><!----></button></ni-button>
</form>

Text Content

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Principal Legal First Name
Principal Legal Last Name
Principal Email Address
Phone Number
Agency Type
Select type

Agency Website
Principal Agent National Producer Number
What is your agency’s total written premium?
What percentage is Commercial premium?
What percentage is Small Business? (Accounts less than $25k)
Submit
Information entered into this form, regardless of submission, is collected in
accordance with our Privacy policy
Our appointment process
 1. Submit your information using the form to the right. Upon submission, you
    will be notified of your approval status and prompted to sign our Producer
    agreement.
 2. Once you sign the Producer agreement, we will verify your licensing
    information. If we are unable to verify your agent or agency license, we
    might reach out to you for additional information.
 3. Once we verify your information, you will receive a welcome email with your
    login credentials


Already applied?
If it was less than 1-2 business days, please allow time for processing. If you
are following up on your application status or have other questions, reach out
to appointments@nextinsurance.com or 855-222-5919.
Who we insure
We are trusted by 420,000+ small business owners across more than 1,300 classes
of business including, but not limited to General Contractors, Janitorial
Services, Restaurants, Daycares, Retail Stores, Insurance Professionals,
Hairstylists, Fitness Instructors, Business Consultants, Real Estate Agents,
Accountants, and many more
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