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Main/Primary Location Info
*
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Gross Annual Revenue (Excluding Profit Sharing)
*
Age Of Agency
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Number Of Office Locations
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0 (Remote)
1
2
3
4
5
More Than 5
Mix Of Business
*
List out the percentage of revenue in your agency book of business that is personal lines, commercial lines, life, health, benefits, etc
Top 10 Carriers By Policy Count
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Direct Written premium By Line Of Business
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Loss Ratios For Top 10 Carriers
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Please include the last 12 months of loss ratios and any special circumstances (abnormal area cat losses, etc)
Any Employees?
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Yes
No
Employee Count and Tenure
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Any Network Affiliations?
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Yes
No
Examples would be: aggregators or clusters (SIAA, PIIB, etc)
List Any Network Affiliations
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Agency Owner Name (Primary)
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First
Last
Agency Owner Phone
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Agency Owner Email
*
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