Become an Agent

Become a Producer

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

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: