Agency Information Sheet

Agency Name

Physical Address

City

State

Zip Code

County or Parish

Phone Number

FEIN

Marketing Contact

Email Address

Licensing Contact

Email Address

Document E-Delivery Email

Accounting Document E-Delivery Email

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

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

WORKERS' COMP AGENCY INFORMATION SHEET