Company Information
Name of Firm:
Principal Address :
Mailing Address :
Phone:
Fax:
Are you a:
Corporation Partnership Individual
Taxpayer ID # :
 
Principal and Personnel
1
Breakdown of Staff
Number
 
Principals / Partners, Owners
 
Officers, Managers
 
Other Employees
 
Total Staff
 
2
 Principals / Officers / Brokers / Contacts
 
Name
Title / Position
Duties
 
 
 
 
Do you write business outside the state of domicile?:
Yes No
If Yes, please describe which states:
 
Operations
Does your agency operate as wholesalers, MGA, retailer or combination?
Retail:
 %
Wholesale Brokerage:
%
MGA with binding authority:
%
 
Leading Companies Represented and Approximate Annual Volume
Please attach evidence of E & 0 Coverage and copy of Agency License in each state indicated above.
Please Print, Sign and
Fax: 1-877-206-0678 or
Mail to: PO Box 4550
Bremerton WA, 98312