Agent Signup Form
Application for Bankers Contract
I am interested in a Bankers contract for:
BUILDERS RISK
BUSINESS OWNERS
COMMERCIAL GENERAL LIABILITY
EXCESS FLOOD
HOMEOWNERS/DWELLING FIRE
HR/PAYROLL/BENEFITS SERVICES
STANDARD FLOOD
WORKERS COMPENSATION
Company Name
Agency Legal Name:
Agency DBA Name:
Agency Type:
Corporation
Partnership
Sole Proprietorship
LLC
Physical Address
Address:
City:
State:
Zip Code:
Mailing Address (if different than address above)
Address:
City:
State:
Zip Code:
Telephone Information
Telephone Number:
(
)
-
Fax Number:
(
)
-
Tax Identification
Social Security#
Federal Tax ID#
Contact
First Name:
Middle Initial:
Last Name:
E-Mail Address:
Agent Homepage:
Business Longevity
How long has your agency been in business?:
Were there any changes in ownership?:
Yes
No
If yes, when (year)?
What was the prior name?
Additional Agency Information
Number of Licensed P&C Producers:
Number of Licensed L&H Producers:
Number of Personal Lines CSRs:
Number of Commercial CSRs:
Does agency currently or in the past represent Bankers?:
Yes
No
If yes, provide Producer Code:
Any other business (e.g. real estate) conducted from premises?:
Yes
No
Has any carrier terminated the agency in the past 3 years for production and/or adverse loss ratio?:
Yes
No
Any judgements or suits pending against the agency?:
Yes
No
Any license suspensions in the past five years?:
Yes
No
Any account current or unearned commission balances past due to any company?:
Yes
No
Is the agency affiliated with a national or regional brokerage firm?:
Yes
No
Is the agency a member of PIA?:
Yes
No
Is the agency a member of IIAA?:
Yes
No
Is the agency a member of LAAIA?:
Yes
No
List any other organizations:
Overall premium size of agency:
Distribution of agency business (must equal 100%):
Personal:
%
Commercial:
%
Life & Health:
%
Agent Flood Information
Flood Partner #1:
Estimated Premium:
# of Policies:
Flood Partner #2:
Estimated Premium:
# of Policies:
Flood Partner #3:
Estimated Premium:
# of Policies:
Percentage of current flood policies willing to rollover to Bankers:
%
Sub-Offices
Does agency have any branch or sub-office:
Yes
No
If yes, please provide name(s) and address(es):
Name1:
Address:
City:
State:
Zip Code:
Name2:
Address:
City:
State:
Zip Code: