New Agency Appointment Request

Message To:

Please select the state in which you would do business:

Message From: * Required

Legal Name:

Telephone:

E-mail Address:

Physical Address:

City:

State:

Zip:

County:

Tax Id:

Agency Name as licensed:

Questionnaire: * All fields are required

Agency Appointment Type:

Personal

Commercial

Both

Agency Type:

Corporation

Partnership

Individual

Date Established:

Branch Office Locations (if applicable):

Geographical Territory (list counties):

Has any insurance company cancelled its connection with your agency in the last three years? (if yes, explain)

Yes

No

Top three Carrier Profiles for your agency:

1) Carrier Name:

Total Premium:

% Personal:

% Commercial:

2) Carrier Name:

Total Premium:

% Personal:

% Commercial:

3) Carrier Name:

Total Premium:

% Personal:

% Commercial:

What is your total agency premium?

Total:

Personal:

Commercial:

Would business with Donegal be primarily:

New to Agency

Presently handled by the agency?

Do you accept brokerage business?

Yes

No

What is your potential Donegal volume for the 1st year?

Total:

Personal:

Commercial:

Are you currently part of an agency cluster organization?

Yes

No

Why are you interested in an appointment with our Insurance Company?

Message To:

Message From: * Required

Questionnaire: * All fields are required

Message: