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Brokerage / Agency Questionnaire

Basic Info

Legal Name *
DBA (If any)

Phone Number *
Fax Number
Agency Email Address *

Type Of Operation *  Corporation Partnership Sole Proprietorship DBA- Attach Certificate Other- Explain
Contact Person(s) In Brokerage/Agency*
 

Number Of Locations *
Physical Address   
Street *
City *
State *
Zip*
Mailing Address
Street *
City*
State*
Zip*


History

Year Firm Established *
During the past (5) years has the firm acquired/merged with another firm?*
Yes No   If yes, please provide details   
Are you a member of any of your state’s local association(s)? *
Yes No   If yes, please list   
Is producer engaged in, owned by, associated or affiliated with, or controlled by any other business interest?*
Yes No    If yes, please explain   

Next

Principal & Personnel

List In Order Of % Ownership
Name * Title * Years Of Ownership * Years With Firm * Percent Ownership *

License Staff
Name * Title * Years With Firm * License Number * Email *

Accounting

Contact Name * Contact Number * Email *

Operations

Do you write business outside state of dominicile?*    Yes No
If so, are you licensed in those states?   Yes No
If yes, explain
E&O Carrier*
E&O Per Occurrence Limit*
E&O Annual Aggregate Limit*
E&O Deductible *

Does your brokerage / agency operate as a wholesaler or MGA?
 Yes No
 Wholesale MGA (Binding Authority)
Is your agency licensed as an excess and surplus lines broker? *
 Yes No  If yes, does your agency operate in this capacity, please explain   
Is your agency licensed as/ owned by a reinsurer, insurer or other insurance organization?*
 Yes No   If yes, please explain   
Do you receive business from brokers / agents dominciled outside of florida?*
 Yes No    If yes, please explain   
If you are placing business on behalf of others (i.e. agents/ brokers, MGA/wholesale capacity) is there an agreement as respects submissions and premium payments.*
 Yes No    If yes, please attach a Copy of agreement   
Agency Management System*

Total Agency Premium *
Personal Lines Premium *
Commercial Lines Premium *

Agency Premium Volume

Name * Years Represented * Annual Volume * Loss Ratio * Binding Authority*

Premium Volume Based on Class of Business


Class of Business Current Year * Prior Year * Loss Ratio % *
Condo Associations
Townhome/HomeOwner's Associations
Apartments/Townhomes
Office-Professional and Medical
Specialty Program Bussiness,Please Explain
Total

Production Expertise

What classes of business does your agency specialize in?*

Claims

Does agency have in house claims support* Yes No
If yes, Please explain


Marketing-Advertising

Please briefly describe you primary methods of marketing and advertising*

Is the agency involved with any trade associations ?*   
Yes No   If yes, please explain   

Please submit questionnaire along with below listed items

E&O- Fidelity Dec

Production Reports From Main Carriers

Loss Ratios- Reports (If not included in above)

Copy of W-9

Now that the hard work is done, share with us an interesting fact about yourself (or)
Your agency. Do you have any favorite hobbies or pastimes?

Declaration

The undersigned hereby declares that the answers given with respect to the foregoing questions are true complete and accurate with no misrepresentations,omisions, or any other concealment of fact.
Title *
Signature of Applicant *

Review and submit        

Basic Info :


Legal Name:  

DBA (If any):  

Phone Number :  

Fax Number :  

Agent Email Address :  

Type Of Operation:  

Contact Person(s) in Brokerage/Agency:  

Number Of Locations :  

Physical Address:  

Mailing Address :  

History:


Year Firm Established:  

During the past (5) years has the firm acquired/merged with another firm?      
If Yes, please provide details:  

Are you a member of any of your state's local association(s)?      
If Yes, Please List :

Is producer engaged in, owned by, associated or affiliated with, or controlled by any other business interest?    
If Yes, please explain :  

Principal(s) & Personnel:


List In Order of % Ownership

Name Title Years Of Ownership Years With Firm Percent Ownership

License Staff

Name Title Years With firm License Number Email

Accounting

Contact Name Contact Number Email

Operations:


Do you write business outside state of dominicile?  
If so, are you licensed in those states?  
If Yes, explain:

E&O Carrier : 

E&O Per Occurrence Limit: 

E&O Annual Aggregate Limit: 

E&O Deductible: 

Does your brokerage / agency operate as a wholesaler or MGA?  

Is your agency licensed as an excess and surplus lines broker?    
If Yes, does your agency operate in this capacity, please explain:  

Is your agency licensed as/ owned by a reinsurer, insurer or other insurance organization?  
If Yes, please explain:  

Do you receive business from brokers / agents dominciled outside of florida?  
If Yes, please explain:  

If you are placing business on behalf of others (i.e. agents/ brokers, MGA/ wholesale capacity) is there an agreement as respects submissions and premium payments?
If Yes,Attach a copy of agreement:  

Agency Management System: 

Total Agency Premium:  

Personal Lines Premium:  

Commercial Lines Premium: 

Agency Premium Volume:


Name Years Represented Annual Volume Loss Ratio% Binding Authority

Premium Volume based on Class of Business:


Class of Business Current Year Prior Year Loss Ratio %
Condo Associations
Townhome/HomeOwner's Associations
Apartments/Townhomes
Office-Professional and Medical
Specialty Program Bussiness: Please Explain
Total:

Production Expertise:


What classes of business does your agency specialize in?

Claims:


1.Does agency have in house claims support?  
If Yes, please explain:  

Marketing - Advertising :


1.Please briefly describe you primary methods of marketing and advertising:  
2. Is the agency involved with any trade associations?  
If Yes, please explain:  

Please submit questionnaire along with below listed items:


Now that the hard work is done, share with us an interesting fact about yourself or your agency. Do you have any favorite hobbies or pastimes? :  

Declaration:


The undersigned hereby declares that the answers  given with respect to the foregoing questions are true complete and accurate with no misrepresentations,omisions, or any other concealment of fact.

Title:     Signature of Applicant: