New Strategic Member

Staregic Master Agency

Agency Legal Name:

Person of Contact:

First Last

Home Address:

Street Address City State / Province / Region ZIP / Postal Code

Business Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Total Premium Volume:

New Business (Rolling 12)

City Population:

Agency Management System:

Number of Employees:

Number of Accounts:

Years in Business:

Area of Expertise:

Years of Expertise:

Insurance Assoc. Membership:

Marketing Plan:

Yes

Marketing Plan Objective:

Perpetuation Plan:

Yes

Mix of Business:

Personal

Commercial

Life/Health

Other

Carriers Wanted:

Current Carries:

Referral Source:

Staff Name, Position, Email Address 1:

Staff Name, Position, Email Address 2:

Staff Name, Position, Email Address 3:

Staff Name, Position, Email Address 4:

Staff Name, Position, Email Address 5: