In order to be considered for an Agency Appointment with Consumers Insurance, we will need to know the following information regarding your agency operation. Due to the current volume of applications, please allow 4 - 6 weeks for review.

Agency Name:
Street Address:
Mailing Address:
E-Mail Address:
County:
State:

Phone:			Fax:
How Long in Business?

How did you learn of Counsumers Insurance?

Agency Personnel

Agency Principals:
Total # of employees?

To whom should "Agency Management" correspondence be addressed?

Agency Writings

Year	Amount
			% Personal
			% Commercial

Top 4 Carriers Represented - Volume and Loss Ratio

Hard copy documents may be requested

Company Name	Ratio - Volume

General Agency Questions

Agency Management System?(AMS, Applied, etc.)

Describe Retail Location (Visability from the Street, etc.):

Why would this agency appointment be successful?

List 3 Company Representatives and contact info for reference purposes. --Phone numbers, or E-mail addresses. Will you provide written permission to contact? Yes No

List any Company contracts that have been terminated in last 3 years. --Give date of contract termination and detailed explanation

List any professional associations you are member of, and original date of membership

Held any office in professional associations?(Past/Present)

General Comments

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