Affiliate Application

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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?*

Do 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?*

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Phone

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27898