Tell us about yourself and your agency.

Legal Name of Agency *

Year Established

Agency Phone Number *

Agency Website

Number of Locations

Agency Physical Address [Primary Location] *

Type of Agency *

Corporation LLC LLP Sole Proprietor

Sole Proprietor

First Name Last Name

Tax ID

Primary Contact *

First Name Last Name

Primary Contact Phone Number *

Primary Contact Email Address *

Is the primary contact the agency Principal?

YES NO

Best day of week to connect;

Monday Tuesday Wednesday Thursday Friday

Best time of day to connect;

Morning Afternoon Evening

Tell us about your agency sales.

Agency Premium *

$5M or below $5-$10M $10-$25M Greater than $25M

Agency Annual Growth Rate *

(%) percentage

What products does your agency handle [check all that apply] *

Personal Lines Business Insurance Marine Management Liability Professional Liability Surety

Tell us about how your agency operates.

What are the TOP THREE carriers you do business with?

What line of business are you seeking an appointment for? *

Commercial lines Personal lines Both Personal and Commercial Lines

Is your agency a member of a cluster, network, or aggregator? *

YES NO

Agency Employees:

	Commercial Lines	Personal Lines
# of Producers
# of support staff / CSRs

Agency Customers:

	Commercial Lines	Personal Lines
# of Customers

Does your agency use a Service Center for these lines of business? *

Commercial Lines Personal Lines Not at this time

Tell us why your agency would like to represent The Hanover.