* Fee paid by appointing insurance company.
** Add $6 per Florida county.
Appointment Fee Form
For your privacy and protection, credit card payments may only be accepted by telephone.
Please call (800) 474-4467, option 5 to authorize a credit card payment.
NOTE: Your initial resident appointment fee is refundable upon the submission of your first application.
State Resident and Nonresident Appointment Fees
If payment is for appointment fee(s), please indicate the state and fee(s) to be charged.
These fees are charged by each state’s department of insurance and are subject to change.
Producer Name: __________________________ National Producer Number: ___________________________
Not For Consumer Use
34547-G-0315
State Resident Nonresident State Resident Nonresident
Alabama $30 $30 Missouri No Fee No Fee
Agency $30 Agency $30
Alaska No Fee No Fee Montana No Fee No Fee
Arizona No Fee No Fee Nebraska $8 $8
Arkansas Fee Paid* Fee Paid* New Hampshire $25 $25
Agency $25 Agency $25
California $29 $29 New Jersey $25 $25
Agency $29 Agency $29 Agency $25 Agency $25
Colorado No Fee No Fee New Mexico No Fee No Fee
Connecticut No Fee No Fee Nevada $15 $15
Agency $15 Agency $15
Delaware $25 $25 North Carolina $10 L/$10 H = $20 $10 L/$10 H = $20
District of Columbia $25 $25 North Dakota $10 $10
Agency $25 Agency $25 Agency $10 Agency $10
Florida $60 $60** Ohio $15 L/$15 H=$30 $15 L/$15 H=$30
Agency $15 L/$15 H
= $30
Agency $15 L/$15 H
= $30
Georgia $10 $10 Oklahoma $30 $30
Agency $30 Agency $30
Hawaii No Fee No Fee Oregon No Fee No Fee
Idaho No Fee No Fee Pennsylvania $15 $15
Agency $15 Agency $15
Illinois No Fee No Fee Rhode Island No Fee No Fee
Indiana No Fee No Fee South Carolina Fee Paid* Fee Paid*
Iowa No Fee No Fee South Dakota $10 $20
Agency $10 Agency $20
Kansas $5 $5 Tennessee $15 $15
Agency $5 Agency $5
Kentucky $40 $50 Texas $10 $10
Agency $100 Agency $120 Agency $10 Agency $10
Louisiana $20 $20 Utah No Fee No Fee
Agency $20 Agency $20
Maine $30 $70 Vermont $60 $60
Agency $30 Agency $70
Maryland No Fee No Fee Virginia $10 $10
Agency $10 Agency $10
Massachusetts $75 $75 Washington $20 $20
Agency $75 Agency $75 Agency $20 Agency $20
Michigan $5 $5 West Virginia $25 $25
Agency $5 Agency $5
Minnesota $30 $30 Wisconsin $16 $40
Mississippi $25 $25 Wyoming $15 $15
Agency $15 Agency $15
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MP $150
MP Agency $150
MP $150
MP Agency $150
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