Atlas General Agency

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Agency Name
FEIN or SS#:

FEIN or SS#: Incorrect Format. FEIN Format: xx-xxxxxxx. SS Format: xxx-xx-xxxx

Entity Type:

Entity type not selected

Physical Address:
City:
State:
Zip:

Mailing Address (if different)
City:
State:

Zip:
Phone #:

Phone: Acceptable Format - xxx-xxx-xxxx

Fax #:

Additional Information:

Owners/Principal:
Owners/Principals Email Address:

Office Manager/Supervisor Email Address:
Main Personal Lines Contact:

What is the business split for your agency?

Commercial

Personal

Total Number of Agency Employees:
Total Number of Personal Lines Staff

Why are you seeking an appointment with our company?

What factors influence where you place your residential property business?

What is your primary focus when selling a residential property policy?

Are any of these markets accessed through an MGA contract?

Yes No

Will Atlas be replacing a current carrier?

Yes No

Does your agency use a Comparative Rater?

Yes No

Which residential property product forms are you most familiar with? (e.g. HOB, TDP-3, ISO-3)

What underwriting challenges does your market represent? (e. g. coastal wind, hail, unusual liability exposure)

How would our market fit in with the other markets you represent?

What production commitment can you make to Atlas General Agency?

Applications per Month
1st Year Premium Commitment:

In addition to the application, we will require current License information, evidence of current Errors & Omission insurance with a minimum $1,000,000 limit and a current, signed W-9 form.

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Atlas General Agency

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