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 *
City, State, Zip *
Agency Principal (2) Name
Phone
Address
City, State, Zip
Agency Principal (3) Name
Phone
Address
City, State, Zip
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? *
Breakdown of Company 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 Error and Omissions insurance coverage? *
What total annual premium volume do you feel you would place with our
Company during the first twelve months of our Agreement? *
Have you ever been appointed, dealt or affiliated with MDOW in the past? *
How did you hear about MDOW? *
Please provide any additional information about your agency
 

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