Agency Information Worksheet
Date
-
Month
-
Day
Year
Date Worksheet is Edited
Producer's Name
Other Not Listed
Al Meier
Angela Davis
Ashley Ward
Bill Schmitt
Bob McAuley
Brad Foote
Carolyn Williamson
Charlene Bauer
Chelsea Nolander
Chris Moulder
Chris Murphy
Chris Stuhlweissenburg
Dan Brown
Dana Kelly
David Fiske
David Senescu
Dustin Schwartz
Erik Lindquist
Greg Harris
Greg O’Connell
Jackie McLaughlin
Jason Lukens
Jay Ferrara
Jennifer Carta
Joe Sylvia
John Grise
Jordan Connelly
Keith Lyon
Klayton Caldiero
Lisa Haaser
Matt Faust
Matt Wischnowsky
Michael McNally
Nicole Rickett
Paulina Stosur
Pete Tichacek
Savie Vath
Sean Smith
Shane Holden
Shane White
Steve Sanford
Sue Williams
Suzanne Averill
Todd Pollock
Vanessa Mathews
Producer's Email
example@example.com
Agency Name
Address
Street Address
Suite/Floor
City
ZIP Code
State
Telephone
-
Area Code
Phone Number
FEIN #
Fax
Years in Business
Website Link
http://www.
Principle Contact
Email
example@example.com
Accounting Contact
Email
example@example.com
Marketing Contact
Email
example@example.com
New Business Contact
Email
example@example.com
Account Renewal Contact
Email
example@example.com
P&C Premium
E&S Premium
Name of Producers
Experience
Specialty
1
2
3
4
5
Top 5 E & S Accounts
Premium
Class of Business
1
2
3
4
5
Top 5 Wholesalers
Premium Volume
Preferred Market Used
1
2
3
4
5
Agency Affiliations
State(s) your Agency can file taxes in
State(s) your Agency holds a Surplus Lines license in
Areas that the Agency specializes in
Areas of growth targeted by Agent
What do you expect from a Wholesaler?
Additional needs/questions?
Any additional data or notes:
This information will be displayed at bottom of PDF
Leadership Form Distribution
Chris Murphy
Chris Moulder
Chris Vallone
John Grise
Jordan Connelly
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