Home - Keystroke Underwriters



AGENCY QUESTIONNAIRE

GENERAL INFORMATION

|Name of Firm | |

|Principal Address | |

|Mailing Address | |

|Telephone | |

|Fax | |

|Accounting Address | |

|Accounting Email | |

|Type of Business | |

|FEIN | |

|Applicant is |Corporation |

|Resident License No. | |

Is the Applicant Firm controlled, owned or associated with any other firm corporation or company?

|YES | |NO | |If yes, please provide explanation | |

| |

|Do you write business outside state of domicile? |YES | |NO | |

|If yes, please list states & attach license schedule: | |

|Do you have branch offices? |YES | |NO | |

| | |

|Premium Volume | |

|Do you maintain fidelity coverage over all officers and employees? |YES | |NO | |

|If yes, please attach certificate of insurance. | |

| |

|Do you maintain errors & omissions coverage? |YES | |NO | |

|Please attach a current certificate of insurance. We are required to maintain proof of coverage |

| | |

Have you or your firm/producers received any disciplinary action and/or complaints by a state insurance department or other regulatory authority within the last 3 years?

|YES | |NO | |If yes, please provide explanation | |

BUSINESS

|What percentage of you agency’s business is (these should total 100%): |

|Property & Casualty | |Life & Health | |

|Do you have a commercial lines dedicated unit? |YES | |NO | |

|What percentage of your agency’s business is (these should total 100%): |

|Commercial | |Personal Lines | |

|What percentage of your commercial business is professional liability? | |

In order for us to properly update our records, please list those persons in your office who may be communicating with us (or you may attach a list):

|Name |Title/Position |Direct Phone Number |Email Address |

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|Signature: | |Date | |

|Title: | |

Please return completed Agency Questionnaire to: compliance@

Keystroke Underwriters

1000 Parkwood Circle, Suite 925

Atlanta, GA 30339

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