Name of Agency:
Contact Name:
Mailing Address, City & State, Zip Code:

Street Address:
Business Telephone:
Fax Number:
Web site address:
Email address:
Agency is: Individual Partnership Corporation
Total Number of Employees:
Number of years in business under present name:
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 Standard Lines Services?


List licensed agent(s) operating in your agency.


Errors & Omissions Carrier:
Expiration Date:

Total Premium Volume
Last Calendar Year:
Projected Curent Year:

Approximate Percent (%) breakdown of business written:
Personal Lines:
Commercial Lines:

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pertaining to any type of insurance related activity held by you or any employee of the agency or organization ever been revoked, suspended, or withdrawn by any regulatory authority?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 in detail:

Thank you for expressing interest. We will contact you upon review of this request.