OFFERING A FULL-RANGE OF COMMERCIAL/BUSINESS INSURANCE PRODUCTS AND SERVICES TO NC AGENTS

  


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If you are interested in establishing a relationship with us, complete the following information and someone from our marketing department will be in contact with you.
      Date: 
      Agency Name: 
      Email Address: 
      Mailing Address:  
      Location Address:  
      City:          State:       Zip: 
      Phone Number:      Fax Number: 
     
     Other locations with same filed tax identification number?  Yes     No
     Name(s) and Titles(s) of Principals: 
    
     Name(s) of ALL Producers in this office: 
    
     Contact Person for Accounting: 
     Commenced Business: 
     Number of Employees: 
     Does your agency currently have E & O?     Yes**     No 
     **Send a copy of your current E & O declarations page listing this location.**
     List 3 principal carriers your agency represents with approx. volume for each: 
    
     With what wholesalers do you write business? 
    
     List specialty lines your agency handles: 
    
     This questionnaire completed by: 
    

     

 
 

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