Local Edge | The Partnership Account® for Insurance Agents

Agency Profile

Name of the person completing the form:

First Name

Last Name

Title: (Example: President)

Email:

Phone number:

2. Owner Information

First name/last name of the owner:

First Name

Last Name

Owner phone number:

Extension, if applicable:

Owner email address:

Additional owners, if applicable:

2. Agency Information

Agency name:

Agency start date:

Agency license number:

Agency website/URL:

Agency email address:

Agency phone number:

Agency address:

City

State/Province

Zip/Postal

Country

Additional location, if applicable:

3.

Number of employees:

Number of customer service representatives:

Number of full-time Property+ Casualty (P+C) producers:

4. Professional Liability Insurance

Do you have Professional Liability Insurance?

Yes

No

Name of the insurance company:

Policy term: (Example: 1/29/26- 1/29/27)

Limits: (Example: $100,000)

5. Premiums

Total agency premium: (Example:100,000)

% of personal lines

% of commercial lines

Any programs?

Are you a member of Local-Edge?

Yes

No

Total agency P+C only when booked annually ($)?: (Example:100,000)

Top 5 company placements for P+C:

Are you able to commit to writing $25k in new business with Colonial Surety Company?

Yes

No

5. Review

I have reviewed the above mentioned information and in the best interest of my knowledge, it is accurate representation of my agency profile.

Yes

Name:

Title:

Signature:

Date:

Captcha

Local Edge Insurance Agency Appointment Application

Agency Profile

2. Owner Information

2. Agency Information

3.

4. Professional Liability Insurance

5. Premiums