Agency Information Request Form

Agency Name: Contact Person:
Street Address: City:
County: State:
Zip: Mailing Address:
Phone: Fax:
Email: Agency Opened: (Year):
Is Agency:

Individual

Partnership

Corporation
Does the Agency Have more than one location?:

Yes

No

 If Yes, How Many?:
How did you hear of PRO Premium?: Password of Choice
(Max of 10 characters):
How would you like to receive your copies of customer notices
(i.e. late; cancel; etc.)?:

Email

Mailed to Agency
How would you like to receive your bi-weekly notice of accounts to be cancelled?:

Email

Fax
Owners/Officers: (Include All Below)
Name: SS Number
Name: SS Number
Name: SS Number
Name of Licensed Agent: State License Number for Agent
Agency State License Number:
(if applicable E. & O. Carrier:		 Please attach copy of your existing/current E&O declarations page
Company Name: Policy #
Exp. Date: Agency Production:
Total P&C Volume: Estimated Annual/Monthly Financed Premium:
Personal Lines: Commercial Lines:
Previous/Existing Finance Company(ies): (Seperate with a comma)
Agency Management System: QQ Binding Password:
(If Using QuickQuote Rating Software)
Does your agency bind policies on TruePremium.com?:
Company/GA appointments currently held: (Names)
1. 2.
3. 4.
5. 6.