New Agency Appointment Request

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Questionnaire: * All fields are required

Agency Appointment Type:
Agency Type:
Has any insurance company cancelled its connection with your agency in the last three years? (if yes, explain)
Top three Carrier Profiles for your agency:
What is your total agency premium?
Would business with Donegal be primarily:
Do you accept brokerage business?
What is your potential Donegal volume for the 1st year?
Are you currently part of an agency cluster organization?