Please complete this form and submit:
 
Contact
Name of Firm
Address
City
State
Postal Code
Telephone Number Ext.
Fax Number
Website
E-mail
 
Tax ID Number
Years in Business
Number of Principals
Name of Principal Title Ownership*
%
%
%
* Total Percentage Equals 100%
Number of other staff
List Branch Offices Title
Note: All branch offices must be appointed separately. Each branch must submit a completed broker agreement, broker questionnaire, an agency license and evidence of E&O coverage.
Has any member of the firm received disciplinary action by a state or had an insurance license suspended or revoked?
 Yes     No
If Yes, please explain:
Has the firm ever had an agency contract canceled by a company?
 Yes     No

If Yes, please explain:

 

List all states in which the firm is licensed:
Are you a retail or wholesale broker?
 Retail     Wholesale
Total Agency Volume
$
Personal Lines (%) Commercial Lines (%)
% %
List top 3 Companies
 Premium Value: $  
 Premium Value: $  
 Premium Value: $  
Line of Business %:
Property %
General Liability %
Crime %
Automobile %
Professional Liability %
Workers Compensation     %
Class of Risks %:
Habitational %
Hospitality %
Contractors %
Allied Health Care %
Architects & Engineers      %
Miscellaneous E & O %
Manufacturing %
Service %
Home State License Number
Expiration Date
Proposed Annual Volume Commitment:
$
What is your target market account size?
 $0 - $10,000
 $10,000 - $50,000
 $50,000 +
Is it customary for your agency to inspect or view insured risk?
 Yes     No
 
Does your agency have E-mail?
 Yes     No
Does your agency supply each employee with an individual E-mail address?
 Yes     No
Does your company have highspeed internet access?
 Yes     No
What agency management system does your organization run on?
 
Name of E & O Carrier
Limits $
Expiration Date
Policy Number
 
List a Bank Reference
Name of Bank
Telephone Number Ext. 
Trust Account Number
Please list 3 professional references



 
You hereby declare that the answers given above are accurate and contain no misrepresentations.
 Agree     Disagree
Your Name
Title