• AGENCY INFORMATION

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  • AGENCY PRINCIPAL INFORMATION

  • AGENCY PREMIUM & PRODUCTION

    Please include all your Agency's combined locations
  • CURRENT MONTHLY NEW BUSINESS PRODUCTION

    Please include all Carriers
  • INDIVIDUAL BACKGROUND QUESTIONS

    * “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. ** “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

  • BUSINESS ENTITY BACKGROUND QUESTIONS

    * “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. ** “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
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  • Agreement and Submission

    As the Agency Principal, I hereby declare the information provided in this questionnaire to be true and correct. When completed, click Submit. If you have any questions about this application or our agency on-boarding process, please contact info@ssiuw.com or Mindy Dees, Operations Director, at 251.923.4472.
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