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Online Producer Questionnaire—Personal Lines Division



Contact Information



(*) Name of Agency:


Type of Entity:



Tax ID #

or Social Security #

  

(if an individual)

(*) Mailing Address:

(*) City:

(*) State:

(*) ZIP Code:

(*) Phone Number:

Fax:

Contact:

(*) E-mail Address:

(*) License #:

(*) EIN:


Employer Identification Number

Year agency established:

Branch Office Locations:




Underwriting

Contact:

Title:

Email:

Phone:




Accounting

Contact:

Title:

Email:

Phone:




IT

Contact:

Title:

Email:

Phone:




If a corporation, list the officers and principal stockholders:

President:

Vice President:

Secretary:

Treasurer:

Bank Name:

Bank Address:




Background Information



Top 5 Companies with which you place business:


Company Name

Annual Written Premium

Loss Ratio




Professional Associations to which you belong:

 

General Agencies with whom you place business:

 



Does your agency solicit business as a General Agency?

 

Do you charge broker fees on new and/or renewal business?

 


Has any officer, owner, principal or partner of your agency ever…


Had a bond cancelled for cause?

 

Filed bankruptcy, been sued, or had a judgment entered?

 

Had an individual insurance license suspended or revoked?

 

Been charged with or convicted of a felony or misdemeanor?

 

Had an agency/broker/producer contract cancelled for cause?

 


Compliance Information



Name of Errors and Omissions carrier:

      

Limit of Liability:

      

Policy #:

      

Deductible:

      

Please describe, in detail, any claims made against your E&O (attach and submit with this questionnaire)

      


Estimated Annual Written Premium/Loss Ratio for the Following Products:


















All fields marked with (*) are required.










Contact info
2072 Orchard Drive, Suite A
Newport Beach, CA 92660

Phone :    1-877-700-NEWS(6397)
FAX:          949-554-0250
E-mail: info@newsinsurance.com