South & Western General Agency, Inc. - Become a Coastal Producer

List the three leading Companies in the Agency:

Years Represented:

Years Represented:

Years Represented:

Thank you for your interest in our Coastal Property Programs. Upon receipt of this brief questionnaire, we will promptly contact you.

Agency Information

Agency Name:

Your Name:

Physical Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Phone:

(

)

Fax:

(

)

E-mail:

Web Site Address:

Are you an existing Producer for South & Western?

Yes

General Information

The Agency is a: (click on one)

Sole Proprietorship

Partnership

Corporation

Year Agency was established:

3.	Number of years the applicant has been in the insurance business:
	Number of years at this agency:

Number of employees:

Total agency volume this year:

Last Year:

7.	How did you hear about our Coastal Property Programs?

8.	You have an Interest in our:

	Site Built Homeowners Program with values to $350,000. (including wind in all 2nd tier counties)
	Manufactured Home/Mobile Home Program (including wind in all 1st & 2nd tier counties)
	Both

9.	Please provide the Agency's volume in the following product lines

	Manufactured Home/Mobile Home Premium Volume: $

	Primary Carrier for Manufactured Home/Mobile Home:

	Homeowners Premium Volume: $

	Primary Carrier for Homeowners:

	Dwelling Fire Premium Volume: $

	Primary Carrier for Dwelling Fire:

When completed click on the Submit button and a Sales Representative will contact you shortly. Thank you for your interest in South & Western.