Agency Owner Name:
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Agency Name:
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Agency Home Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Business Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Owner Cell Phone:
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Agency Office Phone:
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Personal Email of Agency Owner:
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Agency Owner DOB:
Agency Owner SSN:
Resident License #:
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NPN:
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Agency Tax ID:
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What state is your resident license in?
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Are you licensed in other states, if so, which ones?
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If yes, who will be the AOR?
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What wholesalers are you currently appointed with?
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What carriers are you directly appointed with?
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Do any agency owners have non-competes? If so, with who?
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Name of all agency owners:
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Have you ever applied for a carrier and been denied?
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Yes
No
If yes, which carriers?
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Have any agency contracts or appointments been cancelled or terminated in the past 5 years?
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Have any agency owners ever filed an E&O claim?
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Yes
No
If yes, please attach documentation explaining what happened.
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Have any agency owners ever had a fine or disciplinary action from a state department of insurance? If it is later found out that the agency/agent has had a DOI penalty, the contract may be terminated.
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Yes
No
Have any of the agency owners filed for bankruptcy?
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How long have you been licensed in insurance?
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What is your agency’s total premium?
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How many quotes per month, on average, do you submit for Personal lines:
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How many quotes per month, on average, do you submit for Commercial lines:
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What is your average monthly new business premium? (Past year)
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What was your agency’s loss ratio last year?
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Have agency owners or anyone ever pleaded guilty or no contest to, or have been convicted of a felony or misdemeanor?
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Which languages do you speak, other than English?
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What do you need the most to help your agency grow?
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How did you hear about us?
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