UNDERGROUND STORAGE TANK (UST) AGENCY PROFILE FORM

UNDERGROUND STORAGE TANK (UST) AGENCY PROFILE FORM
COMMON SENSE MARKETS
Please fill out the information below and return to:

Fax: (979) 776-4787

E-mail: service@anco.com

Common Sense Markets, P.O. Box 4870. Bryan, 7X 77805
AGENCY INFORMATION
Agency Name
Contact
Mailing Address
City
State
Zip
County
Telephone
Format: (000) 000-0000.
Fax
Website address
E-mail Address
Tax ID
Agency License #
E&O Insurance Carrier
E&O Limit
AGENCY LOCATION
Main Location (City/State)
Satellite Offices (City/State)
Agency location:
OWNERSHIP
Type of Ownership:

Name(s) of Owners, Titles, and Years of Experience

Rows	Name(s) of Owners	Title	Years of Experience PL	Years of Experience CL
2.
3.
4.

Years CL Experience within Agency:
Year Agency Established
Number of years under current ownership
Number of People in these Positions:
Producers/Solicitors
CSR's
Other
Check all Designations held within agency:
Does the agency have ownership in another agency?
Please provide name
Does this agency have ownership in captive?
Please provide name:
Is the agency member of an aggregator, cluster, alliance, etc.?
Please provide name:
Automation System(s) used:
Agency is automated for the following function:
UST CARRIERS & PRODUCTION
UST Carriers & Brokers:

Other
Which Carriers(s) is/are most competitive?

Top 3 UST Carriers:

Rows	Carrier	Written Premium	PIF
1.
2.
3.

AGENCY VOLUME:
Total Agency Volume
Percent of Agency Volume is:
CL
PL
Life/Health
UST
How many UST policies do you currently have in your Agency?
Why are you looking for a new carrier(s)?
What New Business commitment can you make?
First Year PIF
2nd Year PIF
3rd Year PIF
SALES & MARKETING
Check the following that apply to your Agency:
What interests you about Common Sense Markets?
How did you hear about Common Sense Markets?
Should be Empty: