Agency Information Worksheet

Agency Information Worksheet
Date

Month Day Year
Date Worksheet is Edited
Producer's Name
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
Should be Empty: