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Agency appointment application
AGENCY INFORMATION
AGENCY NAME
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Legal entity name
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DBA
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ENTITY TYPE
Corporation
LLC
Partnership
Individual
Other
PRINCIPAL OWNERS
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OWNERSHIP %
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TOTAL AGENCY PREMIUM
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COMMERCIAL LINES %
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Estimated total in-force premium with iSurity after 3 years
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PRIMARY LOCATION
BRANCH NAME
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PHYSICAL
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Address
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City
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State
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Zip
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Phone
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Fax
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MAILING
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Address
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City
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State
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Zip
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BACKGROUND INFORMATION
Has the agency, agency owners, or any agency representatives been involved in an insurance-related lawsuit? If so, explain.
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Has the agency, agency owners or any of its agents filed for bankruptcy? If so, explain.
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Has the agency, agency owners, or any agency representatives filed an E&O claim? If so, explain.
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How did you hear about iSurity?
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APPLICANT INFORMATION
NAME
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EMAIL
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PHONE
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