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Illinois
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Louisiana
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Maryland
Massachusetts
Michigan
Minnesota
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Montana
Nebraska
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New Hampshire
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New York
North Carolina
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Northern Mariana Islands
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Rhode Island
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1. Have you or your firm ever been named in any suit?
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No
2. Have you or your firm ever filed for bankruptcy?
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Yes
No
3. Have you or your firm ever been investigated by the Department of Insurance?
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Yes
No
4. Have you had an appointment cancelled or denied?
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Yes
No
5. How many years in business?
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6. Number of locations?
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7. Number of active producers?
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8. Which comparative rater(s) do you currently use?
9. What is your comparative rater customer number?
10. What agency management system do you currently use?
11. If, you use FSC, please list your Customer Number for each location.
Top Personal Auto Carriers Represented
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YTD Written Premium
Policies in Force
Loss Ratio
Please include a copy of your agency license.
Agency Name
Address
Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip
Phone
Resident License Number
Expiration Date
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