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New Agency Appointment Request
Message To:
Please select the state in which you would do business:
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DC
DE
GA
IL
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VA
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Agency Name as licensed:
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Contact Name:
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Telephone:
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E-mail Address:
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Physical Address:
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City:
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State:
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NC
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PA
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VA
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Tax Id:
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9 digit format, 123456789
9 digit format, 123456789
Questionnaire:
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Agency Appointment Type:
Please select Agency Appointment Type
Personal
Commercial
Both
Agency Type:
Please select Agency Type
Corporation
Partnership
Individual
Date Established:
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Invalid Date Format (mm/dd/yyyy).
Branch Office Locations (if applicable):
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Geographical Territory (list counties):
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Has any insurance company cancelled its connection with your agency in the last three years? (if yes, explain)
Please answer if any connection to your agency has been cancelled.
Yes
No
Please enter the reason for the cancellation.
Top three Carrier Profiles for your agency:
1) Carrier Name:
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Total Premium:
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% Personal:
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1 - 3 Digits
% Commercial:
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1 - 3 Digits
2) Carrier Name:
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Total Premium:
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Digits Only
% Personal:
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1 - 3 Digits
% Commercial:
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1 - 3 Digits
3) Carrier Name:
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Total Premium:
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Digits Only
% Personal:
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1 - 3 Digits
% Commercial:
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1 - 3 Digits
What is your total agency premium?
Total:
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Personal:
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Commercial:
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Would business with Donegal be primarily:
Please answer the primary source of business question.
New to Agency
Presently handled by the agency?
Do you accept brokerage business?
Please answer brokerage question.
Yes
No
What is your potential Donegal volume for the 1st year?
Total:
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Personal:
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Commercial:
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Are you currently part of an agency cluster organization?
Please answer agency cluster question.
Yes
Please enter the name of the Agency Cluster.
No
Why are you interested in an appointment with our Insurance Company?
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