Agency Interest Form
Interested in joining our network of 90+ independent agents? Fill out this form for us to learn more about your agency (responses are confidential).
AGENCY INFO
Agency Name
Website
Date Established
-
Month
-
Day
Year
Date
Type of Business Structure
Individual
Partnership
Corp
S Corp
LLP
Other
Agency Management System
Type of Agency Automation System
Number of Users
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OWNER/PARTNER INFO
List all Owners/Partners below with % of ownership:
Name
% of Ownership
Name
% of Ownership
Name
% of Ownership
Additional Owners/Comments:
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OFFICE LOCATION INFO
Location
City
State
Total Premium
Commercial %
Personal %
Life Health Benefits
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MARKETING AREA
What cities or countries do you consider your marketing area?
Are there any in Tier 1 (Coastal)?
Yes
No
E&O INFO
Name of E&O Carrier
Limits
List any significant claims for last 5 years:
AGENCY REVENUE
P&C Revenue from previous year-end.
P&C Revenue
Other Revenue
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GENERAL QUESTIONS
List any other agencies you are a part of, regardless of whether you have a minority or majority interest:
List any other groups/clusters you are a part of and have a contractual obligation to (i.e., Heartland, etc):
Do you presently have an agency perpetuation plan that would involve, acquisition, merger, brokerage arrangement, change in ownership or style of business? If so, please discuss your plan:
List any other agencies/individuals that you broker business for. Please include specifics (i.e., a copy of any contract in place & the amount of business brokered):
Do you specialize in any certain market or industry where policies are primarily placed through surplus markets? If so, explain (include MGA’s, Program Business, etc.):
In the last 3 years, have you or any insurance companies terminated your relationship with them? If yes, please provide details:
What can CAA do to help you and your agency?
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REFERENCES
Name of Agency/Agent
Name
Phone
Email
1.
2.
3.
4.
Name of Company/Contact
Name
Phone
Email
1.
2.
3.
4.
Submit
Should be Empty: