Retail Agency Profile Form
Agency Name *
Entity Name(if agency name is a trade name or 'dba')
*
Year Established(if less than 3 years, provide resumes on key personnel) *
Mailing Address City State Zip *
Physical Address City State Zip * Same for Physical
Phone # * Fax # * E-mail Address *
Tax ID # *
Agency is: *
Agency Affiliations or Parent Entity (banks,other Agencies , etc) *
Former Name Or Previous Addresses (last 5 Years)
*
Number of Employees(excluding principles and producers) *
Number of Licensed Producers *
Number of Branch Offices(list addresses on separate sheet *
Agency Principals:
Name * Title *
# of Years with Agency * Email *
Name Title
# of Years with Agency Email
** If more than 2, list on a separate sheet.
Other Key Personnel :
Name Title
# of Years with Agency Email
Name Title
# of Years with Agency Email
** If more than 2, list on a separate sheet.
License(s) held by sole proprietor or agency entity :
Type * License # *
Type License #
Type License #
Breakdown Of Agency Revenue :
Commercial Lines * Personal Lines *
Life & Health * Other (Specify) *
Total Agency P&C Premium Volume :
Current Year * Last Year * Previous Year *
Percentage of Premium Written Through Wholesalers *
Describe Specialty in Other Areas
Membership in trade Organizations * Other (Specify) *
Five Largest Insurance Companies Represented :
Name * How Long? *
Name * How Long? *
Name * How Long? *
Name * How Long? *
Name * How Long? *
Other Wholesalers Contracted With :
Name * How Long? *
Name How Long?
Name How Long?
Name How Long?
Name How Long?
Attach :
Please attach a copy of your E&O Insurance Coverage : *
Please attach a copy of your P&C License from Dept of Insurance : *