Agency Application

General Information

Please fill out as much as possible so we can learn about your agency and speed up the application process.

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FEIN (list all FEINs if more than one)
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Agency Ownership

Owner(s) full name Associated % of ownership Number of years in industry
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Agency Executive Leadership

Full name Title
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Agency Operations

Number of years in business
Number of years under current ownership
List any national agencies, networks or brokers you are affiliated with
Note: Attach a copy of the errors and omissions policy or certificate.
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Agency Staff

Number of employees Account managers Account executives Marketing Customer service representatives
Commercial lines
Life

How many active commercial lines producers does your agency
have involved in writing new business?

 
Staff Information
Full name
Email
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Years in insurance
Years in agency
Years in commercial lines
Designations
Industry/SIC focus
Producer revenue

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Agency’s Total Commercial Premium Volume

Line of business Standard Excess and surplus Specialty programs
Property and casualty
Workers' compensation
Farm/Ranch

Top Three Carrier Service Centers

Company Number of years Premium volume

Agency Technology

Agency Growth Plans


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Three-Year Growth and Revenue

One year
Three years
Five years

Agency Percentages

Agency Carrier Profile

Provide prior year-end experience with other carriers in your agency.

Commercial
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Carrier name
Commercial
Premium
Commercial
Loss ratio
Commercial
3-year loss ratio
Personal premium
Bond premium
Life premium
Total premium

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