Thank you for your interest in Avatar Property & Casualty Insurance. Our company specializes in property insurance (homeowners, mobile home homeowners, condominium owners and commercial properties).
If you are interested in becoming an Avatar agent, please complete this questionnaire and return it to
Agency Name: (as indicated on W9)
Location Address
Street AddressCityStateZIP Code
County
Agency Phone Number:
DBA Name (if applicable)
Current # of Employees: ______
Agency E-Mail Address: ______
Business Entity
Year Agency Established
Do you have a current appointment with Avatar?
Yes No
Has any company terminated the agency within the past three years?
Yes No
Association Memberships (Check all that apply)
FAIA LAAIA PIA
Has the agency or any officer, owner, or partner ever experienced the following?
Been charged, arrested, or convicted of a felony?
Had denied, suspended, or revoked any insurance license applied for or issued?
Been disciplined by any insurance regulatory body?
Filed bankruptcy, been sued, or had a judgment entered?
Had any bond contract cancelled for cause?
Had any agency contract cancelled for cause?
None of the above
Agency Coverages
E&O Carrier E&O Policy Limit
General info
LINES OF BUSINESS APPLYING FOR:
Personal Lines ( ) Commercial Lines ( ) BOTH Personal and Commercial Lines ( )
AGENCY BOOK OF BUSINESS BY THE LINE OF BUSINESS (premium and percentage):
Personal Lines ($____AND___%) Commercial Lines ($____AND___%)
AGENCY LOSS RATIO: 1) Non-Irma____% 2) Irma____% 3) Total____
TOP 5 CARRIERS AGENCY WRITES WITH: ______
______
AGENCY OWNER INFORMATION:
Name______
Phone______
Email______
Avatar P&C Insurance
1101 E Cumberland Ave,
Tampa, FL 33602