Granada Insurance Company

General Agency Information

Name of Agency
Physical Address
County
City
State
Zip
Is the physical address the same as the mailing address?	Yes No

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
How did you hear about us?

Agency Commercial Lines Premium For Last 3 Years

2017 Volume ($)
2016 Volume ($)
2015 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

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)