Agency Profile
Submission Form

*Marks Required Fields

What You Need to Know about Contracting with Graham-Rogers
1. Commercial Accounts are agency billed.
2. Contracted agents are responsible for collecting audits, when applicable.
3. In Tennessee, a separate finance agreement is required.
4. In Tennessee, accounts which are premium financed, any returned premium is sent to the finance company.
Name of Agency:
Contact Name:
Mailing Address, City & State, Zip Code:
Street Address:
Business Telephone:
Email Address:
Agency Is: Individual  Partnership  Corporation 
Total Number of Employees:
Number of years in business under present name:
For Principal Agent, how many years of experience (min. 2 yrs. rqd.):
FEIN:
During the past 5 years has the agency
acquired, merged with another firm, or changed names?:		 Yes  No 
If Yes, please provide dates and details:
Name and street address of any other branch offices affiliated with this agency.
Agency is owned by:
How did you learn about Graham-Rogers?:
List licensed agent(s) operating in your agency?:
Errors & Omissions Carrier:
Expiration Date:
Total Premium Volume
Last Calendar Year:
Projected Current Year:
Projected Current Year:
Approximate Percent (%) breakdown of business written:
Personal Lines:
Commercial Lines:
Which lines of business are you most interested:
Other companies agency currently represents (include MGAs & E&S Brokers)
Please include premium volume and loss ratio for each:
Has any company cancelled your agency contract in the last three years?
Yes No 
If Yes, explain:
Has a license pertaining to any type of insurance related activity held by you or any employee of
the agency or organization ever been revoked, suspended, or withdrawn by any regulatory authority?
Yes No 
If Yes, explain:

Thank you for expressing interest. Only thoroughly completed submissions will be considered by the Management Team.