Qualitas El Paso Appointment Request

Appointment Request

Please complete all sections of this questionnaire
General Information
Legal Name*
DBA
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email*
example@example.com
Agency is a*

PartnershipSole ProprietorshipCorporationOther
Date Agency Established*

MonthDayYear
Date

Additional Locations
Please List Any Additional Locations

Ownership
Names and Address of ALL persons having an ownership interest in the agency.*

Employees and Contact Information
Agency Personnel - Key Employees*
Contact in Accounting*
Contact in Customer Service*
Number of Employees*
How Many are Licensed?*
Any part-time Employees? If No, enter 0.*
Have you or anyone in your agency been sued concerning insurance related activities?*

YesNo
If Yes, please explain
Has you, your employees, or your agency been disciplined by ANY State agency or Department of Insurance?*

YesNo
If Yes, please explain
Do you carry Error & Omissions Insurance? - If "No" we will not approve an appointment.*

YesNo

Financial Information
Bank Name*
Bank Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Operating Account*
Trust Account*

Operations
Do you use a Comparative rating system?

YesNo
If Yes, Which one?
Do you use a Agency Automation system?

YesNo
If Yes, Which one?
Agent's Associations to which you belong

IIAAPIAAllianceWAIBOther

Carriers and/or GAs
List Principal Companies (Carriers/GAs) you have Agent/Broker Agreements with, in order of premium volume*
Must include Loss Runs for the past 3 years directly from the carrier or GA to support the loss ratio provided above.
Current Year Written Premium*
Written Premium from last year
Written Premium from 2 years ago

Marketing
Describe the agency's principal marketing territory and demographics
Describe mediums used in advertising
Does the agency market to any specific groups of associations? Please explain.
Office Hours
Office Type

ResidentialCommercialOffice BuildingMallStrip CenterIndustrialOther

Documents and Signature
Please upload copies of the following as part of your applications:
1. Individual Brokers and Agency License(s)
2. Insurance Bond
3. Errors and Omissions Dec Page (Carrier must be "A" Rated of better")
4. Resumes for all principals and key employees
5. Must include Loss Runs for the past 3 years directly from the carrier or GA to support the loss ratio provided in the "Carriers and/or GAs" section.
File Upload

Cancelof
Your Name
Your Title
Today's Date

MonthDayYear
Date
Signature

Clear
Should be Empty: