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General Agency Information
Name of Agency
Physical Address
County
City
State
Zip
Is the physical address the same as the mailing address?
Yes
No
Mailing Address
County
City
State
Zip
Telephone
Fax
Cell Phone
Email Address
Company Website
Agency Background
Year agency was established
Error & Omissions Carrier
E & O Limits
E & O Effective Date
Tax ID#
Legal Entity of Agency
-Select Type-
Individual
Partnership
Corporation
How did you hear about us?
-Select Referral-
Specialty Agents Convention
Insurance Journal Magazine
LAAIA Convention
LAAIA Monthly Meeting
Other
Please specify referral
Agency Commercial Lines Premium For Last 3 Years
2018 Volume ($)
2017 Volume ($)
2016 Volume ($)
Principal Personnel Information
Name
220 License #
Years With Agency
List Companies You Represent
Carrier
Year Licensed
Premium Volume
Does agency specialize in select trade group programs? (Printers, gas stations, restaurants, etc)
Does agency actively solicit commercial lines business?
Yes
No
Solicitation Type
-Select Type-
Phone solicitation
Yellow Pages
Printed Media
T.V. & Radio
Other
Other Solicitation Type Description
Financial Information
List companies with whom you are on account current basis
Have you ever been terminated by a company for failure to remit premium payments?
Have any principal and/or stockholder of agency ever declared bankruptcy?
Applicant's Name
Applicant's position with agency
Narrative (Additional information about the agency that you would like to highlight)