Agent Signup

Prospective Agency Appointment Application

SS# :

Fed ID:

Name of Agency:

Mailing Address

Street Address or PO Box:

City

State

Postal Zip:

Agency Address

Street Address:

City

State

Postal Zip:

Phone:

( ) -

Fax:

( ) -

E-mail:

Resident Address

Street Address or PO Box::

City:

State:

Postal Zip:

Agency :

How long?:

License Number:

Is the Agency in any other business?

Yes No

If so give details:

Name of owners and key employees

Name:	Title:	Years Ins. Experience

References

Bank	Address / Phone	Other References

Other

Agency Volume:

List in the following percentages:

Personal Lines:

Auto:

Property:

Commercial:

Surplus:

Other:

What Agency Management system are you on:

Is Agency affiliated with a bank?:

Yes No

Auto Agency?:

Yes No

Real Estate?:

Yes No

What kind of volume can Beacon expect?:

First Year

%Auto

%Property

P&C Companies Represented

A. Company:		Number of years:
Current year written premium: $
# Months:
Loss Ratio:
1st preceding year written premium: $
%earned loss ratio:
2nd preceding year written premium: $
%earned loss ratio:
B. Company:		Number of years:
Current year written premium: $
# Months:
Loss Ratio:
1st preceding year written premium: $
%earned loss ratio:
2nd preceding year written premium: $
%earned loss ratio:
C. Company:		Number of years:
Current year written premium: $
# Months:
Loss Ratio:
1st preceding year written premium: $
%earned loss ratio:
2nd preceding year written premium: $
%earned loss ratio:
Comments:

It is agreed and understood that Beacon Insurance Group, in the procedure of processing their contract, may make inquires into my character, business and personal reputation, and financial standing, and in doing so have my permission to contact the companies I represent, my bank, business associates, and/or friends and acquaintances.

It is further understood that should the company procure an investigative consumer report, that in compliance with the fair credit reporting act (Public Law 91-508) The company shall upon written request, provide within a reasonable period of time, a complete and accurate disclosure of the nature and scope of such an investigation.