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: |
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|Telephone: |Fax: |
|Agency Email Address: |Website Address: |
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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 | | | | | |
| | | | | | |
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|Commercial Lines | | | | | |
| | | | | | |
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|Personal Lines | | | | | |
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Total Agency P.C. Volume (Last full year):
% Personal: % Commercial:
Direct Bill: Agency Bill:
|Companies Represented |
|Name |Current Annual Premium |Loss Ratio |
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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 |
| | |
| | |
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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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