Agency Information Sheet

* indicates a required field

Agency Name* Physical Address

City

State

Zip Code

County or Parish

Phone Number*

FEIN

Marketing Contact*

Email Address*

Licensing Contact

Email Address

Total Agency Commercial Premium Volume WC Volume

From the categories below, please indicate the percentage of your WC volume they compose

Transportation %

Wood Products %

Agribusiness %

Construction/Excavation %

Oil & Gas %

Manufacturing %

Specify any other class(es) not listed above and percentage Please list any other states besides your state of domicile where you will solicit

WITHIN 1ST 6 MONTHS

# of Submissions

Average Account Size

WITHIN 2ND 6 MONTHS

# of Submissions

Average Account Size

Agency Principal

Title

Date: April 26, 2024

THIS IS NOT A CONTRACT Completion and submission of survey does not guarantee a contract will be issued to your agency.