The Partnership Account® for Insurance Agents: Request Appointment

Name of the person completing the form

First Name

Last Name

Title: Example President

Email

Phone

2. Owner Information

First Name / Last Name of the owner

First Name

Last Name

Owner Phone Number

Extension

Owner email address

Additional owners, if any.

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.

Number of employees

Number of customer service representatives

Number of full-time 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?

Total agency P+C when annually booked

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 and why?

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?

Insurance Agency Appointment Application

2. Owner Information

2. Agency Information

3.

4. Professional Liability Insurance

5. Premiums

5. Review