Agency Profile - AmTrust North America

More documents

Recommendations

Info

Office Profile: Please include anyone that may be using our online system to get premium indications and quote. This will allow us to communicate with your agency via e-mail. Key Personnel Responsibilities E-Mail Total number of employees: Number of active commercial producers: Any recent changes in ownership Yes No If yes, please explain: Any plans for mergers or acquisitions Yes No Primary marketing territory: Describe your agency management system: Is the agency in good standing with its home state Has the agency, any of its officers or management ever been convicted of a crime, excluding minor traffic offenses Other Companies: List companies in decreasing volume order: Yes No Company: Company: Company: Personal: Commercial: Personal: Commercial: Personal: Commercial: Prior Year WP L/R 2 nd Prior Year WP L/R Any company changes in last three years Company Added Terminated Reason Added Terminated Added Terminated AmTrust North America, Inc. - 2 - Agency Profile
Work Comp Markets: List companies in decreasing volume order: Company Prior Year WP L/R 2 nd Prior Year WP L/R Any company changes in last three years Company Added Terminated Reason Added Terminated Added Terminated Note to Applicants: The Violent Crime Control and Law Enforcement Act of 1994 (18 U.S.C. §§ 1033 and 1034) provides as follows: “Any individual who has been convicted of any criminal felony involving dishonesty or a breach of trust, or who has been convicted of an offense under this section, and who willfully engages in the business of insurance, shall be fined as provided in (this law) or imprisoned not more than 5 years, or both.” Please initial Attached copies of resident license for the agency and each listed agent. For New York, please provide your P&C New York license. Attached copy of Agent’s Errors & Omission Insurance declaration page, showing name of carrier, coverage dates, limit of liability and deductible. A minimum limit of $1 million is required. Certification: I have read this application and certify that the answers and information herein are true and correct to the best of my knowledge. Signature: Title: Date: AmTrust North America, Inc. - 3 - Agency Profile Edition: 4/2010
Page 1: 5800 Lombardo Center Cleveland, OH

Agency Profile - AmTrust North America

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?