Agent Application

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General Information

Agency Principals:

	Name	% Ownership	SSN / Tax ID	Birthdate
1:
2:
3:
4:

Business Type:

Production

Percentage of total agency volume

Current carriers utilized for new residential property business

	Carrier	Last Year Volume ($)	Last Year Loss Ratio (%)	Est. New Monthly Applications
1:
2:
3:
4:

Miscellaneous

Has any member of your agency been fined, suspended, or received disciplinary action by a state insurance department or other regulatory authority? YesNo

Has any carrier cancelled or declined to renew your business in the past 3 years? YesNo

Comments

The maker of the foregoing application hereby authorizes Wellington Risk Insurance Agency, Inc. to confirm items comprising this application and to conduct or order any investigation deemed necessary to establish qualifications. The Undersigned hereby certifies that all information provided is current and factual to the best of his or her knowledge. Electronic Signature Disclosure