First Name *

Last Name *

Company

Street *

City *

State *

Zip *

County *

Email *

Phone *

Website *

What Social Media Platforms do you use? *

Do you have a comparative rater? *

If yes, what rater do you have

If other who is your rater

Do you have a management system *

Management system used

If Other, provide name of system

Years of Ownership *

Licensed CSRs *

Number of Licensed Producers *

Number of Branch Offices *

What is the Agency Total Written Premium? *

Book Breakdown of Commercial % *

Book Breakdown of Personal Auto % *

Book Breakdown of Home % *

Affiliated with a cluster or aggregator? *

If Yes, Provide name

Carrier 1 Name *

Carrier 1 Premium Volume *

Carrier 1 Loss Ratio % *

Carrier 2 Name *

Carrier 2 Premium Volume *

Carrier 2 Loss Ratio % *

Carrier 3 Name *

Carrier 3 Premium Volume *

Carrier 3 Loss Ratio % *

Average Monthly New Quote-Personal Auto *

Average Monthly New Quote – Home *

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