The Partnership Account® for Insurance Agents: Request Appointment

1. Agency Profile

Name of the person completing the form:

First Name

Last Name

Title: (Example President / Independent Insurance Agent)

Email:

Phone:

2. Owner Information

First Name / Last Name of the owner:

First Name

Last Name

Owner Phone Number:

Phone 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

Additional locations, if any (optional):

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)

Limits: (Example: $100,000)

6. Premiums

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

Any programs?

Are you a member of a clustor/aggregator?

YES

NO

If yes, which one?

The total agency P+C when annually booked: (Example: $100,000)

Top 5 company placements for P+C:

Top 5 wholesale placements for P+C:

Do you currently place Surety and Fidelity Bonds for your clients?

Yes

No

Where do you currently obtain your Surety and Fidelity Bonds from?

Which Surety or Fidelity Bonds do you currently place?

What is your annual total Surety / Fidelity Bond premium?

What products are you interested in placing with Colonial Surety Company?

Why are you interested?

What is the expected first year commitment? (Example: $100,000)

2nd year commitment? (Example: $100,000)

3rd year commitment? (Example: $100,000)

Do you prefer direct billing or agency billing?

Direct Billing

Agency Billing

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:

How did you hear about us?

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Insurance Agency Appointment Application