Fillable AGENCY PROFILE (Special Risks)

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AGENCY PROFILE (Special Risks)

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The AGENCY PROFILE (Special Risks) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 139 other fields

Country of origin: US
File type: PDF

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1
AGENCY PROFILE
Agency Name: ___________________________________________________________________________________
Federal Employer ID: ______________________________________________________________________________
Address: ________________________________________________________________________________________
City: _______________________________________________________ State: ____________ Zip: _______________
Phone: _________________________ Email Address: __________________________________________
Date Business Commenced: ________________________________________
Agency Is: Individual _______ Partnership _______ Corporation _______ Other _______
List all Licensed Agents in your Agency:
Name D.O.B. Home Address SS#
Date
Licensed
Agency Stockholder Information:
Name of Stockholder Home Address
% of Stock
Held
Bank References:
Branch Address
Type of Account
Agency Accounting Email Address: __________________________________________________________________
Does your agency have Errors & Omissions Insurance Coverage?: Yes ________ No ________
Provide the name of the insurance carrier: ____________________________________________________________
Policy Limits: _________________________________________ Policy Expiration Date: ______________________
2
Agency Premium Volume & Breakdown:
Total Agency Premium
$
Commercial Lines %
%
Personal Lines %
%
Excess & Surplus Lines %
%
Standard Insurance Carriers Currently Licensed with your Agency:
Company
Date Licensed
Have you ever been cancelled by a wholesaler or finance company? If yes, please provide explain:
Company
Reason
What lines of business, industries, and target markets are you interested in placing with Special Risks?:
Line of Business:
Target Markets/Industries:
Property & Casualty
Cannabis, Hemp, Marijuana
Professional/E&O
Construction & Contractors
Directors & Officers
Energy, Oil & Gas
Employment Practices Liability
Environmental Risks
Cyber/Data Security
Healthcare & Social Services
Transportation (Trucking & Public Auto)
Financial Services
Garage
Hospitality (Hotels, Motels, Bars, Restaurants)
Liquor Liability
Manufacturers, Distributors (Products)
Excess & Umbrella
Professional Services & Consulting
Workers Compensation
Real Estate & Habitational
Personal Lines
Other (describe):
Other (describe):
Other (describe):
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND FACTUAL TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
PRINTED NAME: _________________________________________________________________________
SIGNATURE: ____________________________________________________________________________
DATE: _______________________________
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Completed 9 July 2021

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