Non-Appointed Agents | Workers' Compensation & Businessowners' Policies

Legal Business Name

DBA (if applicable)

Business Type

Entity

Corporation

Partnership

Individual

Physical Location

Physical Location City

Physical Location State

Physical Location Zip

Mailing Address (If different than above)

Mailing Address

City/Town

State

Zip

Telephone Number

Website

How long has your agency been in business? Years

Principals of Agency

What is your agency’s Resident State? What is the license number for the Resident State?

How many commercial Producers?

How many commercial Account Managers?

Production

Toal premium	Commercial Lines %
Personal Lines %	Empoyee Benefits %
Number of Commercial Customers	Average Premium Size
Prior Year Growth %	Current Year Planned Growth %
Prior Year Retention %	Current Year Planned Retention %

Areas of focus or specialization:

If appointed with WCF, what is the estimated premium your agency would write in the first year? $

Name and title of person completing application

Email address of person completing application

Phone number of person completing applications

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