Santee Risk Managers llc - American Loggers Insurance



PRODUCER PROFILE

Please identify your agency

|Name: |      |Telephone: |      |

|Street: |      |Fax: |      |

|City -State-Zip: |      |Email: |      |

|Principals: |      |

Business Structure:

|Corporation |      |Partnership |      |Single Ownership |      |

Insurance Affiliations

Please list two Companies you currently represent with the address of your service office. The person(s) listed may be contacted for references.

|Company: |      |Company: |      |

|Contact Person & Title: |      |Contact Person & Title: |      |

|Tel: Fax: Email: |      |Tel: Fax: Email: |      |

General Information

a. How long has the agency been in business?      

b. Do you or anyone in your agency carry a Surplus Lines License? If so please attach a copy:      

c. Approximate annual premium volume of the agency - split by class

|Ocean Marine |      |Inland Marine |      |Property |      |

|Casualty |      |Other lines (Please identify) |      | |

d. Total number of officers and staff:      

e. Details of Errors and Omissions Coverage including carrier, limits and deductible:      

Please attach a copy of the E & O declaration page:

f. Please confirm you operate a separate Premium Trust Account on behalf of Insurers:      

Bank Reference

Please supply details as below:

|Name of Bank: |      |

|Address: |      |

|Phone: |      |Fax: |      |

|Person to contact and title |      |

|Name: | |Title: | |Date: | |

| | | | | | |

|Signature | | | | | |

Revised 04/01/16

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download