Connected Agency Data Sheet
Please complete all required fields!
Date
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Name of Agency
(*)
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Resident License Number
(*)
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Social Security Number or TAX ID number
(*)
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NPN Number
(*)
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Phone Number
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Street Address
(*)
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City
(*)
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State
(*)
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Zip
(*)
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Mailing Address
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City
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State
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Zip
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Agency is
Individual
Partnership
Corporation
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Year Established
Only numbers
First Name
(*)
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Last Name
(*)
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Date of Birth
(*)
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Agency E-Mail Address
(*)
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Agency web site
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Overall written P&C volume of the agency (all lines)
Under $1 Million
$1-$3 million
$3-$5million
$5-$10 million
$10+ million
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Percentage of your agency by
Commercial
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Personal
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Annual Commercial Auto Premium Volume
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Do you have access to carriers through a cluster-group type arrangement?
Yes
No
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Name of the cluster
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How many Commercial Auto Carriers do you work with within your agency?
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How many new Commercial auto applications do you quote per month?
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How many new Commercial auto policies do you writer per month?
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Do you use a comparative rater?
Yes
No
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Which one for Commercial Auto
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Name of comparative rater
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Check the states you are licensed
(*)
Arizona
Illinois
Indiana
New Mexico
Tennessee
Texas
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Salesperson Name 1
(*)
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Salesperson Name 2
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Salesperson Name 3
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Salesperson Name 4
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Salesperson Name 5
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Salesperson Email 1
(*)
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Salesperson Email 2
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Salesperson Email 3
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Salesperson Email 4
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Salesperson Email 5
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Salesperson Phone number 1
(*)
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Salesperson Phone number 2
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Salesperson Phone number 3
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Salesperson Phone number 4
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Salesperson Phone number 5
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