Appointment Application

Agency Name?

DBA Name?

Email Address?

Agency Address?

Phone?

Fax?

Website?

How Did You Hear About Us?

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E&O Carrier?

E&O Policy Effective Date?

E&O Policy Limit?

E&O Policy Deductible?

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Please tell us about your agency. How does the premium breakdown by industry type?

Please list the top 3 companies you place business with.

What Is The Total Written Premium In Your Agency?

How Many Producers Do You Have?

Please Tell Us What Your Average Premium Is By Industry.

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Why Do You Need Another Market?

Please Tell Us About Your Sales Pipeline.

Have You or Any Partner of Your Agency:

Had a complaint filed against you by the dept. of insurance? Filed Bankruptcy? Had an E&O claim charged against you? Had an agency contract terminated? None of the above

If so, please explain:

By signing below you certify that the information given on the appointment application is complete and accurate to the best of your knowledge. You understand failure to provide complete, accurate and truthful information on the appointment application will be grounds to deny or withdraw your appointment.

Agency Principal Signature

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