The Brethren Mutual

Insurance Company

Agency

Appointment

Application

149 North Edgewood Drive, Hagerstown, Maryland 21740-6599

Agency Name:
Agency Address:
Agency Telephone #: / Agency Fax #:
Agency Website Address: / ______

AGENCY E-MAIL

Agency Principal E Mail Address:
Personal Lines Contact E-Mail Address:
Commercial Lines Contact E-Mail Address:
Farm Lines Contact E-Mail Address:
Accounting Contact E-Mail Address:
General Contact E-Mail Address:

(for software and correspondence regarding technical issues)

AGENCY ORGANIZATION

FORM
Sole Proprietor / “C” Corporation / Federal ID #:
Partnership / “S” Corporation
TYPE
Agency / Managing General Agency / Managed Cluster Group
Brokerage / Shell Cluster Group / Other
General Agency / Marketing Cluster Group
PARTNERS OR CORPORATE OFFICERS
Name / Title / Address
LICENSE INFORMATION Attach copies of agency license and agent licenses (include date of birth and
social security numbers for each agent).
MD PA VA
MANAGEMENT Please list the following individuals in your agency:
Agency Personal Lines Supervisor / Agency Commercial Lines Supervisor
Agency Claims Supervisor / Agency Licensing Contact
PRODUCERS (including principals) / CUSTOMER SERVICE REPRESENTATIVES
# of Commercial Lines producers / # of Commercial Lines CSR’s
# of Personal Lines producers / # of Personal Lines CSR’s

MARKETING

PREMIUM VOLUME
Agency Premium Volume
Total written premium for most recent calendar year: / $
Total Personal Lines written premium for most recent year: / $
Personal Auto / $
Homeowners / $
Other Personal / $
Total Commercial Lines written premium for most recent year: / $
BOP / $
Commercial Package / $
Commercial Auto / $
Workers Compensation / $
Farm / $
Other Commercial / $
Excess and Surplus Lines / $
MARKETING EMPHASIS (Target Markets)
Line or Class of Business / Volume
$
$
$
$
$
Does the agency have any specialty programs? / Yes / No
If yes, please describe:
Does the agency accept brokered business? / Yes / No
If yes, please explain:
Describe producer’s methods to attract new business:

CARRIER HISTORY

List companies currently representing:
TOP FIVE CARRIERS
Company / Attach copies of production/experience reports from these carriers for the past three (3) years and year to date.
Describe any authority granted by carriers (e.g. underwriting prices, claims drafts, etc.)
List companies discontinued in the last three years and the reasons:

AGENCY OPERATIONS

AGENCY MANAGEMENT SYSTEM
Type:
Capabilities: / Accounting / Word Processing / Proposals
Rating / Interface / Diary
Internet Access
AGENCY ERRORS & OMMISSIONS
Yes / No / If yes, attach a copy of declaration page of Errors & Omissions Policy

AGENCY BACKGROUND

Is insurance agency’s only business? / Yes / No
If no, list others and percentage of business for each:
Does agency have perpetuation plan? / Yes / No
If yes, please describe or attach a copy:
Agency’s Bank Reference:
Agency’s Founding Date:
Significant Changes in agency:
Business, Community and Personal Affiliations:
What are agency’s expectations from Brethren Mutual?
Agency Principal’s Signature / Date

Edition Date 7-26-2010

Page 1