Affiliate Application Your privacy means everything to us. We keep your information completely confidential, so you can have peace of mind when you fill out and submit this form. "*" indicates required fields Step 1 of 4 25% Please complete each field. If not applicable, type NA.Legal Name:* List of all Owners and Percentage of Ownership*Federal ID Number:* Street Address:* Mailing Address:* Phone Number:*Fax Number:* Email:* Mobile Number:* General Information:Please complete each field. If not applicable, type NA.How many years has agency been in business?* How many years under present ownership?* Does the agency operate or engage in other business at its locations? (Real Estate, Tax, Investments, Bill Pay, etc.)* Please list 3 things that you would like your agency to achieve by joining 1Source?*Number of licensed staff?* Number of producers?* What is your geographic marketing territory?* Do all employees/producers have a non-compete agreement?*SelectYesNoDo employees/producers sign an NDA on behalf of your agency information?* Marketing Information:Please complete each field. If not applicable, type NA.Total Agency Written Premium for prior year?* Total Agency Written Premium previous 3 years?* Is E & O coverage in force for the previous 5 years?* Any E & O claims in the last 10 years? If so, please explain in detail.*Any company contract terminations in the last 24 months? Please explain in detail.*What Percentage of your client base is based on the following:Life %* Health/Benefits %* Personal Lines P/C %* Commercial Lines P/C %* What percentage of your agency is with the following:Standard Market %* Non Standard %* Specialty %* Captive Programs %* List top standard carriers:Please provide in a separate spreadsheet a list of all carriers/brokers you currently represent and receive revenue from and the prior YTD total written premium for each. Please include Loss ratio for all standard carriers. Upload Here*Max. file size: 300 MB. More Information:Please complete each field. If not applicable, type NA.Has any agency principle declared bankruptcy in the last 10 years?* Has any individual currently with your agency been convicted of a felony?* Has any individual currently associated with your agency ever had their insurance license suspended or revoked or had fines or penalties imposed against them by any insurance department?* CAPTCHACommentsThis field is for validation purposes and should be left unchanged.