Prospective Member Agency Profile

Name of Agency *

Industry

Business Type

Tax ID (TIN)/Employer ID Number (EIN)

Agency Address - United States

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Agency Address - Canadian Province

Address Line 1

Address Line 2

City

Province

Postal Code

Agency Details

Telephone country code *

Phone number *

Fax

Website

Agency Ownership

Shareholder 1 - Full name *

Shareholder 2 - Full Name

Shareholder 3 - Full name

Total number of principals

Total number of employees

Have there been any changes in ownership in the last five years? If so, please briefly describe.

Do you have any plans for changes in ownership in the next several years?

What is your agency perpetuation plan and how is it funded?

Total Agency Revenue

Agency Revenue By LOB

Total P/C Premiums (Last fiscal year)

In what particular classes of business, specialty programs or service facility, if any, does your firm specialize? Please list the key individuals in each of these areas.

Please describe any outside ownership or any stock pledged.

Please list the companies you represent and the approximate volume of business.

Please list all your out of state branch offices (if any):

Is your agency a subsidiary of or affiliated with any other organization or corporation?

Have you or any of the agents in your agency ever had your insurance license(s) suspended or revoked by the Department of Insurance or similar regulator?

PLEASE ATTACH YOUR AGENCY BROCHURE

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PLEASE ATTACH A BRIEF HISTORY OF YOUR FIRM