Agency Information Form - Associated Mutual Insurance ...



|[pic] |Associated Mutual Insurance Cooperative |

Thank you for your interest in becoming an Agent with

Associated Mutual Insurance Cooperative.

If you are a licensed property/casualty producer and would like to explore a relationship with us, please complete the Agency Information Form below.

The completed questionnaire should be forwarded to:

Associated Mutual Insurance Cooperative

Attention: Marketing

P.O. Box 307

Woodridge, NY 12789

Or, you may email or fax it instead.

Email: Marketing@

Fax: 845-434-5430

|[pic] |Associated Mutual Insurance Cooperative |

| |Woodridge, NY 12789 |

| |Phone: 845-434-4550 Fax: 845-434-5430 |

| | |

Agency Information Form

|Date Completed:       |Region No:       |

|Agency Name:       |

|Location Address: |Mailing Address: |

|      |      |

|Telephone:       |Fax:       |

|Agency Email Address: |Website Address: |

|      |      |

Corp. Individual Partnership TBA

|SSN:       |Federal ID:       |Established:       |

Banking Reference: Name:      

Branch:      

Address:      

P&C License:      

(Attach copy of current license)

If an Individual, Date of Birth:      

Name of Agent’s E&O Carrier:      

(Attach current copy of Declarations page)

Policy No:       Policy Period:      

Do you ever accept Brokered Business, or have a working arrangement with any outside brokers?

If yes, explain:     

|Key Personnel |

| |Principal or Officer |Title |Licensed? |How Long? |Email |

|Accounting |      |      | |      |      |

| |      |      | |      |      |

| |      |      | |      |      |

|Claims |      |      | |      |      |

| |      |      | |      |      |

| |      |      | |      |      |

|Commercial Lines |      |      | |      |      |

| |      |      | |      |      |

| |      |      | |      |      |

|Personal Lines |      |      | |      |      |

| |      |      | |      |      |

| |      |      | |      |      |

Total Agency P.C. Volume (Last full year):      

% Personal:       % Commercial:     

Direct Bill:       Agency Bill:      

|Companies Represented |

|Name |Current Annual Premium |Loss Ratio |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

Has Agency ever been terminated by a company?

If yes, by whom and for what reason(s)?      

Does Agent represent a U.R.B Affiliated Company?

If yes, list below:

|Name |Current Annual Premium |

|      |      |

|      |      |

|      |      |

Attach 3 years yearend production experience reports for all companies.

|Region No:       |Agent’s Code Assigned:       |

|Binding Code:       |Agt-1 to Department:       |

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