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Agency Name:
*
Producer Name:
Title:
Address:
*
City:
State
Zip:
Phone Number:
Email Address:
Website:
How many years has your firm been in business?
*
Does your firm have multiple locations?
*
Yes
No
If yes, how many?
Total Employees:
Total CL Employees:
PL Employees:
Total Premium Volume: $
Total Premium Volume CL: $
Total Premium Volume PL: $
2017 CL New Business: $
2017 PL New Business: $
Total EQ/DIC Premium Volume: $
Total CL EQ Premium Volume: $
Total PL EQ Premium Volume: $
2017 CL EQ New Business: $
2017 PL EQ New Business: $
Top 3 CL Business Segments (example: LRO, Restaurants, Office, etc):
Top 3 Carrier Relationships Commercial Lines:
Top 3 Carrier Relationships Personal Lines:
Top 3 Carrier Relationships EQ/DIC?
Are you currently placing business through an Aggregator, Cluster or Network?” If Yes, please list.
Do you currently use online rating platforms?
Name of Agency Management System:
Name of Third Party Rater:
Producer’s IT Contact:
Phone:
Email:
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