Let's work together - RIC Insurance General Agency

Agency Owner / Principal Name*
First Last
Agency DBA*
Agency Corporation Name*
Legal Entity*
Exclusive Agency?*
If Allstate, Allstate Agent #
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address (if different from above)
Street Address Address Line 2 City State ZIP Code
Phone*
Cell Phone*
Fax*

What is the approximate premium size of your agency?*
Of your total agency production, what percentage is personal lines?*
When added to Commercial Lines, Total Agency Production should equal 100%.
Please enter a number from 0 to 100.
Of your total agency production, what percentage is commercial lines?*
When added to Personal Lines, Total Agency Production should equal 100%.
Please enter a number from 0 to 100.
Who makes decisions about which markets to use?*
- Producers
- CSRs
- Other
Active producers your agency has*
Classes of business your agency specializes in*
Which carriers do you work with on a direct basis for commercial lines?*
Which carriers do you work with on a direct basis for personal lines?*
Which General Agencies (GAs) and Wholesalers do you currently work with?*
Does your agency write Surplus Lines business?*
- Yes
- No
Which Surplus Lines brokers do you work with?
What has your experience been with the key GAs/Surplus Lines brokers that you are currently using?
- Excellent
- Good
- Bad

What is most important to you in building a partnership with RIC?*
Agency Contact Information
Agency Contact*
First Last
Agency Email*

This should be the email address for the person who receives any and all email correspondence relating to this submission. S/he would then forward any emails received from RIC as needed.
Correspondence Preference*
- Email
- Fax
Please indicate how you would like to receive notifications on cancellations, endorsements, commission statements, etc.
Application Completed By:*
First Last
Title*
Hidden
HIDDEN FIELD / NOT WORKING ON FRONTEND. Please attach copies of licenses, E&O and bond. These will be required to move forward with the appointment process.
Accepted file types: jpg, pdf, doc, docx, xls, xlsx, Max. file size: 128 MB.
If licensed in more than one state, please attached copies of agent and agency licenses. If an Allstate Agent, please include the CEM (Commercial Expanded Market) course completion certificate. Upload limit: 128MB.
Please attach copies of licenses, E&O and bond. These will be required to move forward with the appointment process.*
Drop files here or

Accepted file types: jpg, pdf, doc, docx, xls, xlsx, Max. file size: 200 MB.
If licensed in more than one state, please attached copies of agent and agency licenses. If an Allstate Agent, please include the CEM (Commercial Expanded Market) course completion certificate. Upload limit: 128MB. File types allowed: jpg, pdf, doc, docx, xls, xlsx

Let’s work together