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8500 Shawnee Mission Pkwy,
Suite 200,
Merriam, KS 66202
877-812-8216
Find an Agent: Producer Appointment Questionnaire
Agent or Broker:
Agent
General Agent/Broker
Producer's Name:
*
Producer's Address:
*
City:
State:
Zip Code:
County:
Branches (if any) List Full Address(es):
Telephone Number:
*
Fax Number:
*
Producer Type:
*
Individual
Partnership
Corporation
License Number:
Tax ID Number:
Background Information
How long has agency/brokerage been established?:
*
years
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:
Is the agency/brokerage owner, controlled, associated or affiliated with another company or business?:
*
Yes
No
If you answered yes, please explain:
Type of agency/brokerage:
*
Commercial
Excess/Surplus
Personal
Specialty
Does your firm have any sub agents, brokers or solicitors?:
*
Yes
No
If so, how many?:
In what states are they located?:
List all states in which your firm is licensed beginning with your resident state and including any non-resident state(s):
*
Do any of your employees devote most of their time to boats/yachts?
*
Yes
No
If you answered yes, please explain:
Name(s) of banks and other references:
Owners(s) and Principals
Name & Address
Title/Position
Years Ins. Experience
Years w/Your Firm
Name
1:
*
Title 1:
*
Experience 1:
*
Firm 1:
*
Name
2:
Title 2:
Experience 2:
Firm 2:
Name
3:
Title 3:
Experience 3:
Firm 3:
Name
4:
Title 4:
Experience 4:
Firm 4:
Name
5:
Title 5:
Experience 5:
Firm 5:
Premium Volume/Distribution/Companies
Total Agency volumes in last 5 years
Year 1:
*
20
Volume 1:
*
Year 2:
20
Volume 2:
Year 3:
20
Volume 3:
Year 4:
20
Volume 4:
Year 5:
20
Volume 5:
Total premium distribution (last complete year):
*
20
Personal Lines (ex. "boats"):
*
$
Commercial Lines (ex "yachts"):
*
$
Small Boats/Yachts:
*
$
Excess/Surplus:
*
$
Total Volume:
*
$
List companies you represent who write small boats/yachts:
Last complete year: 20
Company Name
Years Represented
Annual Boat/Yacht Volume
Loss Ratio
Company
1:
*
Years 1:
*
Volume 1:
*
$
Ratio 1:
*
%
Company
2:
Years 2:
Volume 2:
$
Ratio 2:
%
Company
3:
Years 3:
Volume 3:
$
Ratio 3:
%
Has any company terminated your agency/brokerage relationship during the past 5 years?:
*
Yes
No
If you answered yes, please explain:
Give reasons for your need of additional small boat/yacht market:
*
Will you be offering Old United an existing book of business?:
*
Yes
No
If you answered yes, 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 you answered 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
If you answered yes, please explain: