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AGENCY QUESTIONNAIRE FedNat Underwriters Thank you for your

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03/12/20
1
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
AGENCY QUESTIONNAIRE
Thank you for your interest in FedNat Underwriters representing FedNat Insurance
Company / Monarch National Insurance Company and other nationally recognized
insurance carriers. Please complete the questionnaire below. Once we have received and
reviewed your questionnaire and documentation, you will be notified of our decision. If you
have any questions please contact us at:
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
Phone: (800) 293-2532
Fax: (954) 308-1397
Email: marketing@FedNat.com
1. FIRM
A. Legal Name of Firm:
B. DBA:
C. Street Address:
City, State, Zip:
County:
D. Mailing Address:
E. E-Mail Address:
F. Telephone: Fax:
Corporation Partnership Individual Taxpayer ID No:
2. BACKGROUND
A. Year Established:
B. During the past 5 years, has the firm acquired / merged with another firm or
has the firm changed names? Yes No
If Yes, please explain:
C. Is producer engaged in, owned by, associated or affiliated with, or controlled by
any other business interest? Yes No
If Yes, please explain:
03/12/20
2
3. PERSONNEL
A. Principals, Officers, and Directors (list in order of % of ownership)
Name
Title/Position
Email Address
%
Ownership
Agent
License #
%
%
%
%
B. List producer’s staff (not listed in (A)):
Name
Title/Position
Email Address
Agent
License #
Do you want emails going to one (1) primary email address? Yes No
If yes, which email address?
4. OPERATIONS
A. Do you write business outside state of Florida? Yes No
If Yes, please explain:
B. Does your firm operate as a retailer, wholesaler, MGA, or combination?
%Retail % Wholesale/Brokerage % MGA
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
03/12/20
3
C. List State Licenses for all individuals:
Issued to
License #
Type of License
***Please attach copies of all your current licenses***
5. PREMIUM VOLUME AND DISTRIBUTION
A. Your total volume the last five years:
20 $ 20 $
20 $ 20 $
20 $
B. List major companies in order of premium volume
Name Authority
Years
Represented
Annual
Volume
Loss
Ratio
Binding
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
03/12/20
4
C. Companies discontinued in the last five years & reason:
D. Committed premium you will send to FedNat in the first 12 months:
$
Need commitment on:
Number of personal lines policies per month
6. FINANCIAL
A. Bank name:
Phone: Contact:
B. Do you maintain E & O Coverage? Yes No
Insurance Company:
Limits: Deductible:
***Please attach copy of E&O Dec Page***
C. Has any member of your firm received any disciplinary action by a state
insurance department or other regulatory authority? Yes No
If Yes, please explain:
D. Is there any pending or threatened litigation or augments within the past years
exceeding $10,000 against the Agency or any of the Principals? Yes No
The undersigned hereby declares that the answers given with respect to the
foregoing questions are true, complete, and accurate with no
misrepresentations, omissions or any other concealment of fact.
Signature of Applicant:
Printed Name and Title:
Date: / /
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
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signature
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03/12/20 5
CREDIT AND CHARACTER REPORT
Please Print Name:
FedNat Underwriters, Inc., in considering your eligibility for, or maintenance or renewal
of, an insurance agent’s appointment or brokerage agreement with FedNat Insurance
Company and/or Monarch National Insurance Company and other nationally
recognized carriers, will obtain and use information about you from a detailed credit
and character report pursuant to Fla. Stat. Section 626.521. AUTHORIZATION
By signing below, you authorize FedNat Underwriters, Inc. to obtain a detailed credit and
character report about you for the purpose described above. This authorization will
remain in effect until revoked by you in writing to: FedNat Underwriters, Inc., Attention
Marketing; PO Box 407193, Ft. Lauderdale FL 33340-7193.
You have the right to make a written request to the reporting agency to provide you with a
complete and accurate disclosure of the nature and scope of any report about you obtained
by FedNat Underwriters, Inc.
Printed Name Date
Date of Birth
Home Phone Number Other names (including maiden name), if any,
by which you have been known
Current Address (include street, city, state and zip code):
Name of Employer, if any Name of FedNat Underwriters, Inc.
Contract Relationship Manager, if
known
Signature
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
click to sign
signature
click to edit
03/12/20 6
All the locations you have
lived during your adult
lifetime (city & state only)
All the locations you have
worked during your adult
lifetime (city & state only)
Location of any high schools,
colleges or graduate schools
you may have attended (city
& state only)
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
03/12/20 7
FELONY AFFIDAVIT ACKNOWLEDGEMENT
The federal Violent Crime Control and Law Enforcement Act of 1994 requires that no
person convicted of a felony involving “dishonesty” or “a breach of trust” participate in
the “business of insurance”. Criminal penalties for violation of the Act apply to
FedNat Underwriters, Inc. and to you; therefore, as a condition of your producer
relationship with FedNat Underwriters, Inc., you are required to answer the
following question:
Have you ever been convicted of a felony involving “dishonesty” or “a breach of trust”?
Yes, I have been convicted of a felony involving “dishonesty” or “a breach of trust”.
No, I have not been convicted of a felony involving “dishonesty” or “a breach of
trust”.
Name
Date of Birth
Date
Producer Code
Agency Name
Signature
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
QUESTIONNAIRE CHECKLIST
PLEASE VERIFY THAT YOU HAVE SIGNED AND INCLUDED THE FOLLOWING:
Agency Questionnaire signed
• Felony Aff
idavit Acknowledgment (all 220 agents who will be signing our
applications need to sign an affidavit)
• Credit and C
haracter Report (all 220 agents who will be signing our
applications need to sign a Disclosure & Authorization)
W-9
E&O Declaration Page
03/12/20
8
FedNat Underwriters
PO Box 407193
Ft. Lauderdale, FL 33340-7193
(800) 293-2532♦Fax (954) 308-1397
DO NOT COMPLETE BELOW – INTERNAL USE ONLY
Date of Visit:
Does agency have a professional store front?
Do you recommend appointment?
Marketer Name:
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Completed 7 March 2022

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