Lockton Affinity Brokerage Request

Please complete the following questions to make the referral transition as easy as possible.

    General Referral Information

    Is this an existing Lockton client or a new client?

    [If existing client] Type of existing client:

    Your information:

    Client Information:

    Additional Referral Information
    Please provide the following information. If you have more than one referral to share, please download the Transition Template, complete it and attach it below.


    NAICS description

    Policy number

    Effective date

    Expiration date

    Insurance company

    Insurance company or wholesale broker

    Agency or direct bill

    Annual pay or installments

    Lockton account executive

    Lockton account manager

    Policy type

    Line of business group

    Estimated premium

    Estimated revenue

    Transition template upload

    If you would like to provide additional information, please upload your client file