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Preliminary Agency Application
Reqiured fields are shaded
Agency Name:
Address:
P.O.Box:
City:
 State:
 Zip:
Phone:
 Fax:
 E-Mail Address:

Corporation     Partnership      Sole Proprietor

Contact Person:
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Companies Represented:
Standard Companies
Property & Casualty
Premium
Loss Ratio
3 Year
Life
Premium
Health
Premium
General Agent
Contract
Yes No
Yes No
Yes No
Yes No
Totals
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Non-Standard Companies Property & Casualty
Premium		 Loss Ratio
3 Year		 Life
Premium		 Health
Premium		 General Agent
Contract
Yes No
Yes No
Yes No
Yes No
Totals
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Life and/or Health Only Companies
Company
Life Premium
Health Premium
Group Life/Health
Premium
General Agent
Contract
Yes No
Yes No
Yes No
Yes No
Totals
 
Reset Life and/or Health Only Companies informatin section!
List Top Two Companies
Life/Health Personal Lines Commercial Lines
Companies terminated in last 3 years
Company Year Reason
Why are you interested in Pekin Insurance?
Brief Agency History
Name of person completing this application Title Date




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