Commercial Lines Questionnaire

General Agency Information

Do you currently have an active Personal Lines appointment with Tower Hill Insurance Group?*

No
Yes

Tower Hill Agency Code

Agency Name: (as indicated on W9)*

Agency Mailing Address*

Street Address Address Line 2 City State ZIP Code

County*

Agency Phone Number

Agency Fax Number*

Tax and/or Federal ID #*

DBA Name*

Agency Website URL

Agency E-Mail Address*

Number of Agency Locations*

Agency is a...*

Corporation
Partnership
Proprietorship

Year Established*

Has the agency had a prior appointment with Tower Hill Insurance Group?*

Has any company terminated the agency within the past three years?*

If YES, please explain in detail in the space provided below.

Agency Coverages*

E&O Carrier:	Policy Number:	Limits:

Association Memberships

FAIA
IIABA
LAAIA
PIA
Other Independent Agent Association

Ownership of Commercial Lines Book?*

Agency
Producer
Combination

Has the agency or any officer, owner, or partner ever experienced the following?*

Been charged, arrested, or convicted of a felony?
Had denied, suspended, or revoked any insurance license applied for or issued?
Been disciplined by any insurance regulatory body?
Filed bankruptcy, been sued, or had a judgment entered?
Had any bond contract cancelled for cause?
Had any agency contract cancelled for cause?
None of the above

If yes, please provide a detailed explanation

Name	Title	Date of Birth:	Insurance License Number:	States Licensed In:	Total Years Licensed:	Email Address:

Commercial Staff	Position in Agency	Email Address	License # (if applicable)

Commercial Lines %	Personal Homeowners %	Personal Auto %	Flood %

Office/Retail	Lessor's Risk	HOA/COA	Commerical Residential	Hotel/Motel	Self/Storage	Mercantile Advantage/Mainstreet BOP:	Other

Commercial Lines Questionnaire

Step 1 of 8

Commercial Lines Prospective Agency Questionnaire

General Agency Information

Commercial Lines Primary Contact Information:

AGENCY PRINCIPAL(S):

Staff Positions

COMMERCIAL: Standard commercial companies agency presently represents

Current Premium Volume: All agency lines of business

Estimated Commercial Business

Required Documents:

Total Agency Premium ($)	Total Commercial Premium (%)	Total Personal Premium ($)

Company Name	Date Appointed	In-Force Premium

Est. Premium ($)	Est. Mix of Business (%)	Source

Est. Premium ($)	Est. Mix of Business (%)	Source

Est. Premium ($)	Est. Mix of Business (%)	Source