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
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