Agent Signup Form


Application for Bankers Contract

I am interested in a Bankers contract for:






Company Name

Agency Legal Name:
Agency DBA Name:
Agency Type:

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

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?:

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?:
Any other business (e.g. real estate) conducted from premises?:
Has any carrier terminated the agency in the past 3 years for production and/or adverse loss ratio?:
Any judgements or suits pending against the agency?:
Any license suspensions in the past five years?:
Any account current or unearned commission balances past due to any company?:
Is the agency affiliated with a national or regional brokerage firm?:
Is the agency a member of PIA?:
Is the agency a member of IIAA?:
Is the agency a member of LAAIA?:
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: