$500
$150 per branch location
$10 for each employee over 5
Agency Information:
Agency Name:
Branches:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Verify Email:
Billing Address:
City:
State:
Zip:
Use Agency Address:
Business Type:
Federal TaxID :
Year Established :
Principal Owner:
First Name :
Last Name :
Phone:
Fax:
Email:
Verify Email:
Additional Information :
Total Agency Staff:
Premium Volume Estimate: (Last three years)
2009:
2008:
2007:
Estimated Total Volume by Line of Business:
Current Year
Anticipated Volume with ACBOA (12mo.)
Commercial:
Personal:
Workers Comp:
Other:
States with PLC License:
(* hold ctrl and click to select multiple state)
I have direct contracts with:
(* hold ctrl and click to select multiple state)
Do you maintain E&O Coverage?
Name of Company?
Limits:
Deductible:
Expiry:
Has any principal or employee ever been requested to appear in court, before any public official, before a committee of any professional or business organization, or otherwise, because of criticism of any conduct relating or not relating to insurance?
Has a license pertaining to any type of insurance related activity and held by any principal employee ever been revoked, suspended or withdrawn by action of any regulatory authority?
Has any principal or employee ever been fined, disciplined, or ordered to discontinue a business practice by any regulatory authority or other public official or court? (not motor vehicle violations)
