APG INSURANCE SERVICES

BROKER QUESTIONNAIRE

Please type or print clearly and be sure to include all the necessary documentation required.

 

A. GENERAL INFORMATION
1.NAME OF FIRM
2.PRINCIPLE ADDRESS:
3.MAILING ADDRESS:
4.TELEPHONE:
5.FACSIMILE:
6.TAXPAYER I.D. NUMBER
7.

Corporation

Partnership

Individual

    
B. BACKGROUND

1.YEAR ESTABLISHED:

2.DURING THE PAST(5) YEARS HAS THE FIRM ACQUIRED/MERGED WITH ANOTHER FIRM, OR HAS THE FIRM CHANGED NAMES?YES NO

IF YES, EXPLAIN

3.IS BROKER ENGAGED IN, OWNED BY, ASSOCIATED OR AFFILIATED WITH, OR CONTROLLED BY ANY OTHER BUSINESS INTEREST?YES NO

IF YES, EXPLAIN

4.ARE YOU A MEMBER OF:

PLA

ILABC

OTHER

5.WHAT RATING SYSTEM DO YOU USE:

FSC

CAIR

COMPARE DATA

OIS

1st RATE

OTHER

   
C. PRINCIPALS & PERSONNEL
1.PRINCIPALS/OFFICERS/BROKERS 
(LIST IN ORDER OF PERCENTAGE OF OWNERSHIP AND ATTACH RESUMES)
  
NAME TITLE/POSITION
AND %OWNERSHIP		 YEAR STARTED IN
INSURANCE		 YEAR STARTED
WITH FIRM
TOTAL NUMBER OF EMPLOYEES

D. OPERATIONS

1. LIST ALL BRANCH OFFICES - ADDRESS AND PHONE NUMBERS

2. TOTAL ANNUAL VOLUME PAST 2 YEARS:

1999

1998
3. VOLUME DISTRIBUTION: $ COMM'L LINES $ PERS'L LINES
4. HOMEOWNERS VOLUME:  $
5. LIST PREFERRED COMPANY APPOINTMENTS 6. LIST GENERAL AGENT APPOINTMENTS

DATE APPOINTED

LOSS RATIO

DATE APPOINTED
A.

A.

B.

B.

C.

C.

         
E. FINANCIAL
1. IF ACCOUNTING IS NOT HANDLED BY MAIN OFFICE, PROVIDE ADDRESS AND CONTACT

CONTACT:

PHONE:
2. BANK REFERENCE
NAME:

CONTACT:
TRUST ACCOUNT Nš:

OTHER:
BANK ADDRESS:
t
TITLE:
DATE: