The Market Survey is not a contract, and completing the survey does not guaratee a contract. Once we have the completed document we will begin the agency review process.
Agency Name
Other entities to be listed under Contract
List any “branch” offices to be included in this Contract:
Mailing Address
Physical Address
City
State
AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MN MS MO MT NC ND NE NH NJ NM NY OH OK OR PA SC SD TN TX RI UT VA VT WA WI WV WY
ZIP
County
Phone Number:
Fax Number:
Email Address:
Marketing Contact Person
Federal ID#
Total Agency Commercial Premium Volume
Workers' Compensation Volume
Current Primary WC Carriers
From the Categories below, please indicate the percentage of your WC volume they compose
Transportation
Wood Products
Agri-Business
%
Construction/Excavation
Oil & Gas
Manufacturing
Specify any other specialty class(es) not listed above and percentage of business:
List any other states besides your state of domicile where you will solicit business:
First six months
Second six months
# of accounts
Average size
Agency Principal
Title
Please click on the SUBMIT button to send the Market Survey to the Amerisafe Marketing department. If you decide to print this form out and complete it manually, please fax it to the Amerisafe Marketing department at 1-800-450-1091 or mail it to: Marketing Department Amerisafe 2301 Hwy 190 West DeRidder, LA 70634
