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Please fill out the following form if you are wanting to contract with Graham-Rogers, Inc. as an agent. We will contact you once we have completely reviewed your completed answers.

Agency Name
Agency Is Owned By:
Agency Contact Name*
First Last
Mailing Address
Street Address Address Line 2 City State ZIP Code
Physical Location
Street Address Address Line 2 City State ZIP Code
Agency Phone #
Agency Fax #
Email
Agency Is......
How many employees? (including yourself)
Number of years in business under present name?
FEIN:
During the past 5 years has the agency acquired, merged with another firm, or changed names?
- No
- Yes
Please Provide Dates and Details
Are there any other branch offices affiliated with the agency?
List
Branch Name Street Address State Zip Phone Fax
Please describe how you heard about Standard Line Services
Please list all licensed agents operating in your agency.
First Name Last Name
Who is your Errors & Omissions Carrier?
Expiration Date of Agency E&O policy
MM slash DD slash YYYY
Total Premium Volume
Total Premium Volume Last Year
Total Premium Volume Projected for the Current Year
Personal Lines:
Commercial Lines:
What other companies/agencies do you currently represent (include MGAs & E&S Brokers)
Comapny Name Premium Volume Loss Ratio
Has any company cancelled your agency contract in the last three years?
- Yes
- No
Explaination for cancelled contract
Has a license pertaining to any type of insurance related activity held by you or any employee of the agency or organization ever been revoked, suspended, or withdrawn by any regulatory authority?
- Yes
- No
Please explain.

Branch Name	Street Address	State	Zip	Phone	Fax

First Name	Last Name

Comapny Name	Premium Volume	Loss Ratio

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Total Premium Volume