Agency Application

Please fill out the Agency Appointment Questionnaire below and a representative will get back to you shortly.

* = Required Information

Name *
Address *
City, State, Zip *
Phone *
Email address *
Agency Name *
Phone *
Address *
Fax # *
Web address *
Agency Principal (1) Name *
Phone *
Address *
Agency Principal (2) Name *
Phone *
Address *
Agency Principal (3) Name *
Phone *
Address *
Where is the majority of business you write located *
How long has your agency been in business? *
Agency's total annual Prop. & Casualty Premium Vol. *
% of Agency's personal lines *
% of Agency's commercial lines *
What is the total Personal Property
Lines (Home & Dwelling Fire) Vol? *
Portion written to surcharge rates? *
Breakdown of Company of annual premium volume, loss ratio for the prior calendar year:
Company
Volume
Loss Ratio
Has your agency ever had a Company contract cancelled? *
If YES, please provide details
Does your agency carry E and O coverage? *
What total annual premium volume do you feel you would place with our
Company during the first twelve months of our Agreement? *
What would be the source of this business? *
How did you hear about Columbia Lloyds? *
Please Provide the name, addresses and phone number of (2) Company References and
(2) Credit References (including contact person):
Company References(2) *
Credit References(2) *
Please provide any additional information about your agency