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Agency Information
Name of Agency:
Mailing Address:
City:
St:
Zip Code:
Date:
Phone:
Fax:
Contact Name:
E-mail Address:
Number of Locations:
Number of Producer Codes:
How many years have you owned this agency?:
How many years have you been a licensed Agent?:
What comparative rater do you use?:
Other:
How do you wish to receive updated information (memos, announcements, etc)?:
If you choose e-mail, please list all e-mail addresses you choose to receive information:
If by MAIL, would you like info sent to each location or to the mailing address?:
How do you wish your commissions to be paid?:
Does your agency use DOWNLOADS?:
If yes, please specify what system:
Type of Business:
Principal Information
Name of Agency:
Mailing Address:
E-mail Address:
Name of Agency:
Mailing Address:
E-mail Address:
Name of Agency:
Mailing Address:
E-mail Address:
Other Appointments
Name:
Annual Volume:
Loss Ratio:
Appt Date:
Name:
Annual Volume:
Loss Ratio:
Appt Date:
Name:
Annual Volume:
Loss Ratio:
Appt Date:
Name:
Annual Volume:
Loss Ratio:
Appt Date:
Licensed Employees
Name:
License #:
Name:
License #:
Name:
License #:
Name:
License #:
Name:
License #:
Name:
License #:
Production
Average Monthly Auto Apps Written:
Expected Monthly Applications with Western General:
Expected Monthly Applications with Western General (USD):
Expected Annual Production with Western General (USD):
License Information
Insurance License #:
E & O Coverage Policy #:
Broker Bond #:
Has your license ever been denied, suspended or revoked?:
Location Information
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #:
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #:
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #:
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #:
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #:
Physical Address:
Mailing Address:
Contact:
Territory #:
Phone:
Fax:
ADR #:
FSC #: