Producer Questionnairey - EliteCover Insurance

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+1 (858) 529-7763

info@ecoverins.com

22647 Ventura Blvd. Suite #132 Woodland Hills, CA 91364

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Please complete all sections of this questionnaire, sign it and return with documents.

Legal Agency Name:

DBA:

Mailing Address:

City

State:

Zip Code:

Phone Number:

Agency License Number:

Date Agency Established:

Website Address:

Email Address:

Physical Address (If different than mailing address):

City:

Mailing Address

State:

Mailing Address

Zip Code:

Mailing Address

Agency is a:

Partnership
Corporation
Sole Proprietorship
LLC

Federal ID or Soc. Sec. #:

Do You have multiple locations?

If Yes, please list additional locations including the lines of business that the office specializes in.

Location 1, Address:

Location 1, Line of Business:

Location 2, Address:

Location 2, Line of Business:

Location 3, Address:

Location 3, Line of Business:

Full name of each individual with an ownership interest in the agency, Owner 1:

Full name of each individual with an ownership interest in the agency, Owner 2:

Full name of each individual with an ownership interest in the agency, Owner 3:

Name of Key Employee 1:

Title:

Employee 1.

Is employee 1 a licensed P&C Agent?

License #:

Employee 1.

Years with Agency:

Employee 1.

Name of Key Employee 2:

Title:

Employee 2

Is employee 2 a licensed P&C Agent?

License #:

Employee 2

Years with Agency:

Employee 2

Name of Key Employee 3:

Title:

Employee 3:

Is employee 3 a licensed P&C Agent?

License #:

Employee 3:

Years with Agency:

Employee 3:

Name of Key Employee 4:

Title:

Employee 4:

Is employee 4 a licensed P&C Agent?

License #:

Employee 4:

Years with Agency:

Employee 4:

Primary Accounting Contact (Name):

Location been Premium:

Primary Accounting Contact (Phone #):

Primary Accounting Contact (Email):

Primary Customer Service Contact (Name):

Primary Customer Service Contact (Phone #):

Primary Customer Service Contact (Email):

Number of Employees in Agency:

How many are Licensed?

Have you or anyone in your agency been sued concerning insurance related activities:

If Yes, please explain:

Have your employees, or your agency been disciplined by ANY state agency or Department of Insurance

If Yes, please explain:

Do you carry Error & Omissions Insurance?

If No, we will not approve an appointment.

Bank Name:

Trust Account #:

Bank's complete mailing address:

Do you have Overdraft Protection on these accounts?

Do you use an Agency Automation System?

If Yes, which one(s)?

Are you interfaced with any carrier?

If Yes, which one(s)?

List any agent associations you belong to:

Name of first principal trucking carrier (by premium volume) with whom you have an agent/broker agreement:

Must include loss runs for the past 3 years directly from the carrier or GA to support the loss ratios provided below.

No. of Years:

With carrier 1.

Annual Premium:

With carrier 1.

Loss Ratio:

With carrier 1.

Name of second principal trucking carrier (by premium volume) with whom you have an agent/broker agreement:

Must include loss runs for the past 3 years directly from the carrier or GA to support the loss ratios provided below.

No. of Years:

With carrier 2.

Annual Premium:

With carrier 2.

Loss Ratio:

With carrier 2.

Name of third principal trucking carrier (by premium volume) with whom you have an agent/broker agreement:

Must include loss runs for the past 3 years directly from the carrier or GA to support the loss ratios provided below.

No. of Years:

With carrier 3.

Annual Premium:

With carrier 3.

Loss Ratio:

With carrier 3.

Name of fourth principal trucking carrier (by premium volume) with whom you have an agent/broker agreement:

Must include loss runs for the past 3 years directly from the carrier or GA to support the loss ratios provided below.

No. of Years:

With carrier 4.

Annual Premium:

With carrier 4.

Loss Ratio:

With carrier 4.

Name of first wholesaler/program administrator (by premium volume) where you place business:

No. of Years:

Wholesaler/Program Administrator 1.

Annual Premium:

Wholesaler/Program Administrator 1.

Loss Ratio:

Wholesaler/Program Administrator 1.

Name of second wholesaler/program administrator (by premium volume) where you place business:

No. of Years:

Wholesaler/Program Administrator 2.

Annual Premium:

Wholesaler/Program Administrator 2.

Loss Ratio:

Wholesaler/Program Administrator 2.

Name of third wholesaler/program administrator (by premium volume) where you place business:

No. of Years:

Wholesaler/Program Administrator 3.

Annual Premium:

Wholesaler/Program Administrator 3.

Loss Ratio:

Wholesaler/Program Administrator 3.

Name of fourth wholesaler/program administrator (by premium volume) where you place business:

No. of Years:

Wholesaler/Program Administrator 4.

Annual Premium:

Wholesaler/Program Administrator 4.

Loss Ratio:

Wholesaler/Program Administrator 4.

Provide the Annual Agency Written Premium for Trucking Lines (including all carriers) for the current year:

Prior Year:

Annual Agency Written Premium for Trucking Lines (Including all carriers).

Prior Year:

Annual Agency Written Premium for Trucking Lines (Including all carriers).

General Information:

Describe the agency's principal marketing territory, including all states where that business is written.

General Information:

Describe mediums used for advertising.