Agency Appointment Application

Agency Data:
Name of Individual or Firm:
Corporation / Partnership / Individual / Limited Liability Co
Principle Address:
Street / City / State / Zip
Mailing Address:
(If different from above) / PO Box / City / State / Zip
Stateappointment(s) requested:
AL / AZ / AR / CA / CO / DC / FL / GA / ID / IL / IN / IA / KS / KY
MD / MN / MS / MO / MT / NV / NM / NC / OK / OR / SC / TN / TX / UT
VA / WA / WV / WI / ALL STATES
If multiple agency locations, please list all other physical locations (attach additional sheets if necessary):
Wholly operated Majority interest Minority interest
Loc Name / Street / City and State / Zip
Telephone / Fax#/Email / Website / Fed Tax ID #
Loc Name / Street / City and State / Zip
Telephone / Fax#/Email / Website / Federal Tax ID #
Home Office: / Licensing Administrator:
Telephone #: / Fax #: / Federal Tax ID #:
Website: / Email:
Key Contacts for audit and collection correspondence:
Name/Title / Phone # / Address / Email/Fax #
Copyright © 2009 EMPLOYERS. All rights reserved. EMPLOYERS and America’s small business insurance specialist are registered trademarks of Employers Insurance Company of Nevada and are marketing brands for a group of companies providing workers’ compensation insurance and services.Insurance is offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and Employers Assurance Company. EMPLOYERS does not do business in all jurisdictions. Please contact your local EMPLOYERS Sales Executive /Field Underwriter or visit
Background:
What year was business established?
During the past five years has the agency or firm acquired/merged with another party or has the agency or firm changed names? Yes No
If yes, please describe:
Agency Personnel:
Business focus of agency's staff: / Commercial
All Other Lines
Total Number of Employees:
For principals/owners provide the following:
Name / Title / Years of Exp. / State / License Number / Email Address / Phone # / Fax #
Attach additional sheets, if necessary.
For property/casualty producers provide the following:
Name / Title / Years of Exp. / State / License Number / Email Address / Phone # / Fax #
Attach additional sheets, if necessary.
Operations:
Does your agency primarily operate as a retailer, wholesaler, MGA or combination (fill in all that apply)?
100% Retail / Wholesale Brokerage / MGA Combination
How is your organization licensed, i.e., agent/broker? Excess and Surplus Lines Broker?
List states in which agency has property and casualty licenses:
What agency automation system do you use?
Premium Volume And Distribution:
Current Year
Estimated Total Agency Commercial Lines Volume: / $
Estimated Total Workers' Compensation Volume: / $
Top Three Workers' Compensation Markets: Please include principle carrier, written premium and loss ratios for the current and prior three years. Please indicate the valuation date of these figures. The following must be completed or you may attach the loss runs to the application.
Carrier Name / ______2008
Premium/Loss Ratio / ______2007
Premium/Loss Ratio / ______2006
Premium/Loss Ratio / ______2005
Premium/Loss Ratio
Agency business expertise/focus:
Insurance And Financial:
Does your agency maintain Errors and Omissions over all officers and employees? Yes No
If so, please indicate the following:
Carrier / Limits / Deductible / Expiration Date
Has any person employed by you or your firm (or the firm itself) received any disciplinary action within the past 10 years by a State insurance department or other regulatory authority or had any license revoked or suspended by a State insurance department or regulatory authority relating to the business of the agency or principal? Yes No
If yes, please explain (attach additional sheets if necessary):
Is there any pending or threatened litigation or judgments within the past five years against the agency or any of the principals relating to the business activities of the agency or principal?
Yes No
If yes, please explain (attach additional sheets if necessary):
Has the agency been terminated by any company in the last three years? Yes No
If yes, please explain (attach additional sheets if necessary):
Please return the following attachments with your completed application: / Resident and/or Non-Resident Agency Licenses for All Producers
Most Recent Financial Statement
Errors & Omissions Declarations Page
W-9
Background Authorization forms where required
We agree to permit Employers Insurance Company of Nevada and/or Employers Compensation Insurance Company (hereinafter “EMPLOYERS®”) to conduct any investigation and contact any organization or individual who has any knowledge of our company, the owners or principals of the agency or any individuals employed by our company as EMPLOYERS deems necessary to process this application. This background investigation may include a financial investigation for credit information and/or credit history, review of public records, and inquiry to SIRCON. We agree to execute any authorizations, releases or other documents required by EMPLOYERS to conduct such investigation whenever requested by EMPLOYERS to do so.
We warrant and represent that the statements and answers above, as well as any attachments provided, are true and that no information has been omitted or misrepresented and can be relied upon to be fully accurate. Any omitted or misrepresented information may result in the termination of appointment.
Agency Appointment Application Completed By:
Name / Title / Date
Completion of this application is for evaluation purposes only. Agency appointments are made at the sole discretion of Employers Insurance Company of Nevada and/or Employers Compensation Insurance Company.
Company Use Only
Application Received:Date
Application Reviewed:Date / SIRCON Report: Yes No
OFAC Compliance: Yes No
Application Complete Yes No
Company Approvals:
Sales Executive:
Signature and Date
Regional V.P. Sales:
Signature and Date
Regional V.P. Underwriting:
Signature and Date
Regional President:
Signature and Date
Effective Date of Appointment: / Producer Code:
Appointment Rejected:Date
Reason(s) Rejected:

AAUN015FMAgency Appointment Application

Revised: 06/29/2009

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