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Application for Agency Appointment
General Information
Note: All fields in
bold
are required.
Agency
:
License #:
Agency Principal(s):
Tax ID:
Street Address:
City:
State:
Indiana
New Jersey
New York
Ohio
Zip:
Mailing Address:
Telephone:
Fax:
Email:
Agency Information
Note: Do not use commas or spaces when filling in the information below.
Years in Business:
# of Employees:
# of Licensed:
Total Agency Volume:
Total Agency Volume (Auto):
Non-Standard:
Agency's Total Number of Auto Companies Represented:
Average Number of Auto Apps per Month (previous year):
Average Number of Annual Homeowner Apps:
Primary Company for Standard/Preferred Auto:
Non-Standard Auto:
Homeowners:
How does your Agency advertise (select all that apply):
Yellow Pages
Direct Mail
TV/Radio
Referrals
Other
Has your license ever been suspended or cancelled?
Yes
No
If yes, please explain:
Have you ever been fined by the state?
Yes
No
If yes, please explain:
Systems
Note: All fields in
bold
are required.
Management System Name*:
Version #:
* If you do not have a management system, type "None" in the above field.
Upload/Download:
Yes
No
If yes, Company:
Rating Software:
FSC
OIS/Quoteworks
Company Standalone
Website Rating
E-Z Lynx
Other
ZAP/APP:
Yes
No
EFT:
Yes
No