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?
NewExisting

[If existing client] Type of existing client:

Your information:

First Name (required)

Last Name (required)

Email (required)

Your Lockton Series (required)

Client Information:

First Name (required)

Last Name (required)

Email (required)

State (required)

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

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