Appointment Application

IndividualPartnershipCorporationLimited Liability Company

List all owners of the entity (Partners, Officers, Etc.)

YESNO

(If yes, please explain in detail on a separate sheet)

YESNO

(If yes, please the state, case number and result)

YESNO

(If yes, please give full details including names and reasons)

List all Brokers, Solicitors, Producers, Sales Persons, etc. who are placing business throughthe Brokerage / Agency

Provide names of the current Agencies and Insurance Carriers you place business with

YESNO

(If yes, provide full details specific classes and L.O.B.)

Percentage of the gross income that originates from these lines of business:

YESNO

(If yes, please provide details below)

Bank References:

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