Common use of Agency Information Clause in Contracts

Agency Information. Please complete and return 2 copies for participation in the COMPANY's Mass Marketing Programs. AGENCY Name: Address: County Telephone No. ( ) Fax No. ( ) e-mail address: (circle one below) Partnership Sole Proprietor Corporation or LLC Date Established: Federal ID #: PRESENT PRINCIPALS/SHAREHOLDERS Years Name Title E-Mail Experience @ @ @ @ Number of Licensed Agents/Producers: Total Premium Volume: Premium Mix Personal Lines %Commercial Lines % TOP PREMIUM VOLUME COMPANIES Carrier Branch Office 3 Yr. Loss Ratio MGAs Program 3 Yr. Loss Ratio TERMS AND CONDITIONS

Agency Information. Please complete and return 2 copies for participation in the COMPANY's Mass Marketing Programs. AGENCY Name: Address: County Telephone No. ( ) Fax No. ( ) e-mail address: P (circle select one below) Partnership Sole So artnership Co le Proprietor Corporation rporation or LLC Date Established: Federal ID #: PRESENT PRINCIPALS/SHAREHOLDERS Years Name Title E-Mail Experience @ @ @ @ Number of Licensed Agents/Producers: Total Premium Volume: Premium Mix Personal Lines %% Commercial Lines % TOP PREMIUM VOLUME COMPANIES Carrier Branch Office 3 Yr. Loss Ratio MGAs Program 3 Yr. Loss Ratio TERMS AND CONDITIONS