Agent Application

Agent Appointment Application

Salesforce Form

General Information

Agency Name

DBA

Business Entity Type

Tax ID

Mailing Address

Mailing City

Mailing State

Mailing Zip

County

Location Address is the same as Mailing Address

Location Address

(Please enter full address here)

General Email Address

(For Policy Correspondence)

Agency Website

E&O Carrier Name

E&O Policy Number

Ratio Last month

E&O Policy Expiration Date

Name of Agency Group

Number of Branch Offices

Number of Licensed Agents

Number of Licensed CSRs

Which comparative rater do you use?

What agency management system do you use?

Is there potential for a book transfer?

Year Agency Established

Year Present Ownership Established

List any associations that the agency is a member of

Agency Principal Info

First Name

Last name

License Number

Telephone

Principal Email

Other Agency Contact

Contact

Telephone

Title

Homeowners Written Policy Info

Personal lines policies in force

Mix of Personal Lines Business

Please ensure these percentages add up to 100%

Homeowners

Dwelling

Auto

Flood

How many new HO3 policies does your agency write per month?

How much new business HO premium does your agency write per month?

Anticipated Homeowners written premium with Patriot Select

How many policies per month can you commit to Patriot Select?

Homeowners Carrier Information (Top 3)

Carrier 1

Company Name 1

Total Written Premium

HO3 only Written Premium

Overall Approx. Loss Ratio

Carrier 2

Company Name 2

Total Written Premium

HO3 only Written Premium

Overall Approx. Loss Ratio

Carrier 3

Company Name 3

Total Written Premium

HO3 only Written Premium

Overall Approx. Loss Ratio

Comments