Agent     General Agent/Broker

Producer's Name *

Producer's Address * (Number & Street):

City

State

Zip Code

County

Branches (If any) List Full Address(es):

Telephone Number *

Fax Number *

* Individual   Partnership   Corporation

License Number

Tax ID Number

Background Information

1. How long has agency/brokerage been established? * Years

2. During the past 5 years, has the agency/brokerage acquired/merged with another firm, or has the agency/brokerage changed names? * Yes No
If you answered "yes," please explain.

3. Is the agency/brokerage owner, controlled, associated or affiliated with another company or business? * Yes No
If you answered "yes," please explain.

4. Type of agency/brokerage: * Commercial Excess/Surplus Personal Specialty

5. Does your firm have any sub agents, brokers or solicitors? * Yes No
If so, how many? In what states are they located?

6. Are you enclosing your firm's latest financial statement? * Yes No

7. List all states in which your firm is licensed beginning with your resident state and including any non-resident state(s). *

8. Do any of your employees devote most of their time to boats/yachts? * Yes No
If you answered "yes," please explain.

9. Name(s) of banks and other references:

Owner(s) and Principals

Premium Volume/Distribution/Companies

Total Agency volumes in last 5 years
20 *
20
20
20
20

List companies you represent who write small boats/yachts: *
Last complete year 20

Has any company terminated your agency/brokerage relationship during the past 5 years? *
Yes No - If "yes," why?

Give reasons for your need of additional small boat/yacht market: *

Will you be offering Old United an existing book of business? * Yes No
Please Explain:

Anticipated Old United premium volume: First Year $ Second Year $

Please provide a brief narrative/action plan as to how you anticipate developing the above "estimated" premium volumes:

Do you have "errors and ommissions" coverage? Yes No
If yes: Name of Company/Carrier Limits
Any claims submitted (not necessarily "paid") to your carrier Yes No
If "yes," please explain.

Is there any pending or threatened litigation or judgements within the last 5 years against the agency/brokerage or any principles? * Yes No
Please Explain: