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Form and List
Corporate Name
Corporate Name
DBA/Agency Name
DBA/Agency Name
Street Address
Street Address
Mailing Address
Mailing Address
City
City
State
State
Zip Code
Zip Code
Primary Contact Name
Primary Contact Name
Email Address
Email Address
Phone
Phone
Fax
Fax
Web Site
Web Site
Tax ID Number
Tax ID Number
Date Agency or Location Established
Date Agency or Location Established
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Agency Book of Business Percentage(s) – Please indicate the percentage of your book of business in the following lines
Homeowners/Dwelling %
Homeowners/Dwelling %
Mobile Homes %
Mobile Homes %
Auto %
Auto %
Commercial %
Commercial %
Life/Health %
Life/Health %
Other %
Other %
What is the average number of HO/DP Policies written per month
What is the average number of HO/DP Policies written per month
Is there an opportunity for a rollover
Is there an opportunity for a rollover
Yes
No
If yes. from which carrier
If yes, from which carrier
Agency Production - Please list your five largest personal lines carriers in order of volume
Carrier 1
Carrier 1 Name
Carrier 1 Name
Carrier 1 Premium
Carrier 1 Premium
Carrier 1 Commission %
Carrier 1 Commission %
Carrier 1 Date Appointed
Carrier 1 Date Appointed
RadDatePicker
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Calendar
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Carrier 1 Loss Ratio
Carrier 1 Loss Ratio
Carrier 2
Carrier 2 Name
Carrier 2 Name
Carrier 2 Premium
Carrier 2 Premium
Carrier 2 Commission %
Carrier 2 Commission %
Carrier 2 Date Appointed
Carrier 2 Date Appointed
RadDatePicker
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Calendar
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Carrier 2 Loss Ratio
Carrier 2 Loss Ratio
Carrier 3
Carrier 3 Name
Carrier 3 Name
Carrier 3 Premium
Carrier 3 Premium
Carrier 3 Commission %
Carrier 3 Commission %
Carrier 3 Date Appointed
Carrier 3 Date Appointed
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
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Carrier 3 Loss Ratio
Carrier 3 Loss Ratio
Carrier 4
Carrier 4 Name
Carrier 4 Name
Carrier 4 Premium
Carrier 4 Premium
Carrier 4 Commission %
Carrier 4 Commission %
Carrier 4 Date Appointed
Carrier 4 Date Appointed
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
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February 2019
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February 2019
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Carrier 4 Loss Ratio
Carrier 4 Loss Ratio
Have any carriers terminated their contracts with the agency in the last 3 years
Have any carriers terminated their contracts with the agency in the last 3 years
Yes
No
If yes. Please list the carrier(s) and the reason for termination.
If yes. Please list the carrier(s) and the reason for termination.
Any Additional Comments
Any Additional Comments
Thank you for your interest in our company(s). Our Marketing team will review this information and be in contact within 7 business days.
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