The Partnership Account® for Insurance Agents: Request Appointment

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:

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

Additional locations, if any (optional):

3. Agency Information, Cont.

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 – 1/1/26 -1/1/27)

Limits: (Example: $100,000)

5. 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:

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

5. 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