M. L. I., Inc
PO Box 4550
Bremerton, WA 98312
Phone: (360) 405-1823 / Fax: (360) 405-1829

PRODUCER PROFILE

A. Company Information
1. Name of Firm:
2. Principal Address:
3. Mailing Address:
4. Phone:
Fax:
5. Are you a:
Corporation Partnership Individual
6. Taxpayer ID # :
 
B. 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
Email Address
 
 
 
 
 
C. Operations
1. Do you write business outside the state of domicile?:
Yes No
If Yes, please describe which states:
2. Does your agency operate as wholesalers, MGA, retailer or combination?
Retail:
 %
Wholesale Brokerage:
%
MGA with binding authority:
%
 
D. Leading Companies Represented and Approximate Annual Volume
$
$
$
$
E. Please attach evidence of E & O Coverage and copy of Agency License in each state indicated above.
Also complete and return the attached W-9 form.
Please Print, Sign and
Fax: 1-877-206-0678 or
Mail to: PO Box 4550
Bremerton WA, 98312