Agency Application

General Information

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

*Indicates required field

Agency legal name (list all names if more than one)*

DBA(s)

Key agency contacts (e.g., primary, marketing, claims)

Street address

City

State*

ZIP code

Phone number

Other office locations

Agency website

Incorporation

FEIN (list all FEINs if more than one)
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#FEIN Add FEIN#FEIN

Agency email address*

Agency Ownership

Owner(s) full name	Associated % of ownership	Number of years in industry
			#agencyOwnership Remove

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Agency Executive Leadership

Full name	Title
		#agencyExecutiveLeadership Remove

#agencyExecutiveLeadership Add Leader#agencyExecutiveLeadership

Agency Operations

Number of years in business

Number of years under current ownership

List any national agencies, networks or brokers you are affiliated with

Errors and omissions policy Yes No

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 #staffInfo Remove Years in insurance Years in agency Years in commercial lines Designations Industry/SIC focus Producer revenue

#staffInfo Add Staff Member#staffInfo

Agency's Total Commercial Premium Volume

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

Who are your top three carriers for new business and why?

What are the top five classes of business your agency writes?

Does your agency write small commercial business (under $15,000 in premium)? Yes No

Does your agency have a separate small commercial unit that focuses mainly on small commercial business? Yes No

Top Three Carrier Service Centers

Company	Number of years	Premium volume

Agency Technology

Which agency management system do you use?

System version

What percentage of your new commercial business is quoted via online rating platforms?

Agency Growth Plans

How does a contract with EMC fit into your agency growth plans and goals? Attach an agency business plan if available.

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Three-Year Growth and Revenue

% growth

% revenue

Commercial lines new business

What markets, programs or lines of business will you be using?

Does your agency specialize in any special classes of business? Yes No

What are the main deciding factors in placing business with a carrier?

What is your marketing territory?

What does the sales culture look like in your agency?

What approaches does your agency use to incentivize your sales team?

What other approaches, specifically, does your agency use to generate new commercial business?

How do you currently use social media and how does that fit into your marketing strategy?

What was your sales velocity % last year? (total new written business this year divided by last years' total commissions and fees; e.g., $1.5 million new business/$10 million commission and fees = 15%)

How much premium volume can you commit to EMC in one, three and five years?

One year

Three years

Five years

Three-year total agency revenue

Agency Percentages

Commercial lines

Personal lines

Life

Bonds

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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Agency Application

General Information

Agency Ownership

Agency Executive Leadership

Agency Operations

Agency Staff

Staff Information

Agency's Total Commercial Premium Volume

Top Three Carrier Service Centers

Agency Technology

Agency Growth Plans

Three-Year Growth and Revenue

Agency Percentages

Agency Carrier Profile

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