Agentero: Colonial Surety Company

Name of the person completing the form:

First Name

Last Name

Title: (Example – President / Independent Insurance Agent)

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:

3. 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:

4. Agency Information, Cont:

Number of employees:

Number of customer service representatives:

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

5. Professional Liability Insurance

Do you have Professional Liability Insurance?

Yes

No

Name of the insurance company:

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

Limit: (Example: $100,000)

6. Premiums

Total agency premium: (Example: $100,000)

Percentage of personal lines:

Percentage of commercial lines:

Any programs?

Are you a member of Agentero?

Yes

No

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

Top five company placements for P+C?

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

Yes

No

7. Review

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

Yes

Name

Title

Signature

Date

Captcha

Agentero Insurance Agency Appointment Application