* mandatory fields

General Information

Agency Name*

IRS Tax ID*

xx-xxxxxxx

Existing Agent Code with Heritage, NBIC or Zephyr (if applicable)

Lexis Nexis Node Id

Location Address*

Street Address City State ZIP Code

Location County*

Mailing Address (if different from location)

Street Address City State ZIP Code

Do you have a Retail Location?*

Yes
No

Main Telephone*

Toll-Free Telephone

Fax

Agency Principals

Principal*

First Name Last Name

Title*

DOB*

Email*

License Number*

Principal 2 (if applicable)

First Name Last Name

Email

Phone

Principal 3 (if applicable)

First Name Last Name

Email

Phone

Office Profile

What states do you want to write business in?*

Total Number of Employees*

Any recent mergers or acquisitions?*

Yes
No

Name of Errors and Omissions (E&O) Insurance Carrier

E&O Policy Number

E&O Expiration Date

Do you carry $1,000,000 or more in E&O coverage?

Yes
No

Do you have an Agency Management System?*

Yes
No

Website

Name of agency group

Hold the [Ctrl] key to make multiple selections

Other Professional Organizations or Memberships

Top 3 Personal Lines Appointments

Personal Lines Company*

Personal Lines Company (If Other)

Total Premium*

12-month loss ratio*

Personal Lines Company

Personal Lines Company Other

Total Premium

12-month loss ratio

Personal Lines Company

Personal Lines Company Other

Total Premium

12-month loss ratio

Personal Lines Information

Has your agency ever been terminated by a carrier?*

Yes
No

If yes, provide reason for termination

Average Home Policies Written per Month*

Is there potential for a Book Transfer?*

Yes
No

Mix of Personal Lines Policies in Force

Personal Lines Policies in Force - Homeowners*

Personal Lines Policies in Force - Auto*

Personal Lines Policies in Force - Other*

Agency Signature

Agent Form Completed By Name*

First Name Last Name

Agent Form Completed By Title*

Name

This field is for validation purposes and should be left unchanged.

General Information

Agency Principals

Office Profile

Top 3 Personal Lines Appointments

Personal Lines Information

Mix of Personal Lines Policies in Force

Agency Signature

POLICYHOLDERS

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COMPANY

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