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Agency Application

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Agency Application

Address(Required)
Year Agency Started
Contact Name(Required)

Please note agency commisison REVENUE by Source

SOURCE

PRIOR FULL YEAR

Total Commercial P&C Revenue
Surety Revenue
Benefits Revenue
Other* Revenue

Please indicate percentage of revenue by Industry Class

INDUSTRY CLASS

PRIOR FULL YEAR

Construction
Manufacturing
Transportation
Wholesale Trade
Services (excluding Health Care)
Health Care
Other or Unclassifiable Premium
How many total commercial P&C producers does the agency have?
How many total commercial P&C carriers does the agency represent?

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