Agency Application

Please fill out the Agency Appointment Questionnaire below and a representative will get back to you shortly.
* = Required Information
Agency Name *
Address (no PO box)*
City *
State *
Zip *
Phone *
Fax #
Web address
Contact Name *
Email address *
Tax ID
Agency Principal (1) Name *
Agency Principal (2) Name
Agency Principal (3) Name
How long has your agency been in business ? *
Agency's total annual Prop. "&" Casualty Premium Vol. *
What % of Total P"&"C annual premium is Farmowner/Country Home type risks ?
List agency results and volumes for all companies used to place homeowner, farm & ranch or dwelling risks:
Company
Volume
Loss Ratio
Has your agency ever had a Company contract cancelled ? *
If YES, please provide details
Does your agency carry E and O coverage ? *
Who is your E and O carrier? *
Describe any E"&"O claims within the past 10 years. *
What total annual premium volume do you feel
you would place with our Company
during the first twelve months of our Agreement ? *
How much new premium the next 12 months ?
What would be the source of this business ? *
How did you hear about FarmAssure ? *
Please provide any additional information about your agency

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