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  Prospective Agency Inquiry

 
 
Please tell us about yourself:
*Required
Your Name: *
Agency Name: *
Legal Status: * Proprietorship
Partnership
Corporation
Tax ID: *
Address: *
 
 
City/State: *   
Zip Code: *  - 
Phone Number: *
Fax Number:
Web Site: http://
About your Agency:
 
  Owner Name & Title % of
Ownership		 Social Security Number P & C License
Number		 Date of
Birth
(MM/DD/YY)
1). * 
2).
2).
Owner #1 E-mail:
Owner #2 E-mail:
Owner #3 E-mail:
About your Property & Casualty Carriers:
 
  Largest P & C
Carriers		 Premiums
Written		 Are Loss Ratio reports
available for 3-5 years?
1). * Yes No
2). * Yes No
3). * Yes No
4). * Yes No
5). * Yes No
About your interests in Goodville Mutual:
 
What are your current and long-term interests in Goodville Mutual?  *
How did you learn about Goodville Mutual? *
 
 
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