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Tell us about your agency
Agency Type	RetailWholesale *
Are you an agent with any of the following (select all that apply):	Farmers Nationwide Green Path Next Wave Smart Choice
Licensed Entity Name	*
Physical Location
Address	*
City	*
State	*
Zip Code	*
Do you have a separate mailing address?	YesNo
Mailing Address   City   State   Zip Code
Type of Business	Please Select Type of Business Sole Proprietorship Corporation Limited Liability Company Partnership *
Agency Pricipal Name	*
Agency Principal Email	**
Designated Contact Name	*
Designated Contact Email	**
Phone Number	* - * - *
Fax Number	* - * - *
Mobile Number	- -

 

Complete the following questionaire:	Yes     No
Question Has your agency or any partners, officers, owners, or producers of the agency ever been subject to any Department of Insurance action regarding a violation? Please Explain:	yesno *
Have there been any Errors & Omissions (E & O) claims made against your agency, partners, officers, owners, or producers in the past five (5) years? Please Explain:	yesno *
Has your agency and/or partners, officers, or owners filed for bankruptcy in the past five (5) years? Please Explain:	yesno *
Are there currently any open liens levied against your agency and/ or partners, officers, or owners? Please Explain:	yesno *

Number of construction risks placed yearly	Please select number of risks 0-25 26-50 51-100 100+ *
How would you like to receive your monthly statements?	Please select By Fax By Email *
Please enter the fax number	-   -
Please enter the email address	*
How did you hear about us?	Please tell us how you found us! Email MyNewMarkets.com Referral Trade Show Other
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