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Become an Agent

Form and List

Corporate Name
DBA/Agency Name
Street Address
Mailing Address
City
State
Zip Code
Primary Contact Name
Email Address
Phone
Fax
Web Site
Tax ID Number
Date Agency or Location Established
RadDatePicker
Open the calendar popup.

Agency Book of Business Percentage(s) – Please indicate the percentage of your book of business in the following lines

Homeowners/Dwelling %
Mobile Homes %
Auto %
Commercial %
Life/Health %
Other %
What is the average number of HO/DP Policies written per month
Is there an opportunity for a rollover
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 Premium
Carrier 1 Commission %
Carrier 1 Date Appointed
RadDatePicker
Open the calendar popup.
Carrier 1 Loss Ratio

Carrier 2

Carrier 2 Name
Carrier 2 Premium
Carrier 2 Commission %
Carrier 2 Date Appointed
RadDatePicker
Open the calendar popup.
Carrier 2 Loss Ratio

Carrier 3

Carrier 3 Name
Carrier 3 Premium
Carrier 3 Commission %
Carrier 3 Date Appointed
RadDatePicker
Open the calendar popup.
Carrier 3 Loss Ratio

Carrier 4

Carrier 4 Name
Carrier 4 Premium
Carrier 4 Commission %
Carrier 4 Date Appointed
RadDatePicker
Open the calendar popup.
Carrier 4 Loss Ratio

 

Have any carriers terminated their contracts with the agency in the last 3 years
If yes. Please list the carrier(s) and the reason for termination.
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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