AGENCY QUESTIONNAIRE

General Agency Information

Agency Name (Legal Business Name) Agency DBA Name

Mailing Address City State Zip

Street Address City County State Zip

Telephone Number Fax Number

Social Security Number Agency Manager

Federal Tax I.D. Number __________________________
Agency is a:
Corporation Partnership Sole Partnership Other:
___________________
Changes in Ownership – Prior Name
How long has your agency When?
been in business? _________
Location is:
Main Office Sub-Office for _______________________ Agent # ________________________
Name of Officers, Partners, or Owners:
Name Title Email
Address

Type and Version of Agency Management System

Professional Insurance Organizations

PIAA IIAA State Organization(s) ___________________________________________
Number of Producers: Number of CSRs:
Licensed P & C ___________ Licensed L & H _______ Personal Lines _________ Commercial __________
On a separate sheet, please explain any “YES” answers to the following questions.
1. Any other business (i.e., real estate, property management) conducted on premises? Yes No
2. Has any carrier terminated the agency in the past 3 years for production and/or adverse loss ratio? Yes No
3. Any judgments or suits pending against agency? Yes No
4. Any license suspensions in the past 5 years? Yes No
5. Have you or any licensed agents in your office ever been convicted of a felony crime in any state Yes No
or federal court?
Yes No
6. Any account current or unearned commission balances past due to any company?
Yes No
7. Is the agency affiliated with a national or regional brokerage firm?
Overall Premium Size of Agency Distribution of Agency Business:
$ Personal ________ % Commercial _______% Life & Health ________
%
Flood Production Commitment for the next 12 months: $

QBE INSURANCE COMPANY

Agency Questionnaire
Does agency have any branch or sub offices? Yes If yes, please provide name(s) and address(es).
No
Does agency want sub office(s) set up? Yes
No
Name Contact Person

Address

Telephone Number Fax Number

( ) ( )
List all flood companies you are currently doing business with:
Company Name Estimated Annual Premium Volume
Number of Policies

List all agents that will be writing with QBE: (Attach copy of license and flood training certification for
each agent)
Agent Name Email Address
License Number

ERRORS & OMISSIONS INSURANCE

(Please attach copy of E & O Policy Declaration Page
that indicates limits of coverage, company, expiration date, and deductible.)
Describe any claims:

REQUIRES SIGNATURES AND ATTACHMENTS

The representations and statements made above are true and accurate.

____________________________________ ___________________________________ ________________

Signature Title Date

Completed W-9 (attached) Copy of Your Insurance License

Copy of E & O Policy Declaration Page Signed Contract
COMPANY USE ONLY
Rep Code Initials: New Appointment
 BOB Transfer
Producer Code:
Flood
Agency Contact:
Commission:
Agency Manager: