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Agency Profile

Agency Legal Name*: *:
Agency DBA Name:
Physical Address Mailing Address Same as Physical
Address*: Address*:
City*: City*:
State*: State*:
Zip*: Zip*:
County*:
Phone*:
Fax*:
Email Address*:
Agency Web Site:

*
(If yes, we will need a separate Agency Profile for each location.)

Owner, Agency Principal, or Manager to be appointed with the Company
Name*: Title*:
Date of Birth*: DOI License #*:
E-mail Address*:

Additional Producers to have a login
Name: License Number:
E-mail Address:

Additional Business Information
Years in Business*: # of Licensed Agents*:
Number of CSR's*:

Main Homeowners Carriers*
Carrier Current Year's Volume Previous Year's Volume Loss Ratio

How many Homeowner and Dwelling Fire Policies do you write per month?*

HO3 new rewrite
HO4 new rewrite
HO6 new rewrite
DP3 new rewrite
What percentage HO business is 1995 or newer?*
What is your Approximate Personal Lines Property Premium volume per month?*

Assuming that our rates are competitive and we fulfill our commitment to provide you with an outstanding company/agency relationship, how many policies per month do you believe you could place with Security First monthly?

How did you first hear about Security First Insurance Company?
?
What are the major forms of advertising utilized? Yellow Pages Newspaper Other
If Other, please specify:
?*
*: If other: