Thank you for your interest in National Trust Insurance Services, LLC (NTIS). In 2003, The National Trust for Historic Preservation created a subsidiary - NTIS, to address the growing issues and concerns regarding proper insurance coverage for historic properties and organizations that work to maintain them. Maury Donnelly & Parr, Inc. is the licensed insurance producer for NTIS. Maury Donnelly & Parr, Inc. is licensed in all states except Alaska and Hawaii.

In addition to the attached Brokerage Agreement that must be signed and returned to our agency, please forward the following items with your first submission:

§  Agent Profile form, included in this document

§  W-9 for your Firm

§  Copy of your Agency’s resident insurance license

§  Copy of your Agency’s non-resident license if the risk is located outside of your resident state

§  Copy of Certificate of Insurance, showing your Agency’s Errors and Omissions coverage

For new submissions, the following information will be needed:

§  Completed and signed ACORD application and SOV

§  Completed supplemental application, when applicable

§  Photographs or web address with pictures of structures

§  Loss Runs for the last 3 years

§  Copies of declarations pages from current insurance policies

Again, we thank you for your interest in our insurance program for historic properties, and we look forward to working with you and your agency.

Regards,

Paul LaVardera

Program Director

Agent Profile

Your Name: Email:

Name of Agency:

Mailing Address :

City: State: Zip:

Phone Number: Ext: Fax:

Agency Principal(s):

Accounting/Accounts Payable Contact: Email:

Phone:

Current E&O Carrier:

Number of Locations: / Number of P&C Employees:
Total Agency Volume: / State(s) Licensed:
Personal Lines %: / Commercial %:

Specialized Focus:

Top Standard Market Contracts: Top Wholesale Market Contracts

1) 1)

2) 2)

3) 3)

4) 4)

Have you ever been cancelled by a Wholesale Market? Yes No.

If yes, please explain:

Have you ever been cancelled by a Finance Company? Yes No.

If yes, please explain:

**Please return completed form to Emily Mannix; or fax 443.524.0959**