Agency Information ( * = Required Information)

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• Is this the Headquarters Location? *
  Yes No
• Company Name *
Street *
City *
State *
- Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
Zip *
Phone Number *
Year Established? *
# of Locations? *
- Select a Value - 2 3 4 5+
Agency Legal Status? *
- Select a Value - Sole Proprietor Limited Liability Company Corporation Other
Does your agency have a website? *
Yes No
Website:
Is your agency a member of a cluster, network or aggregator? *
Yes No
Which Cluster, Network or Aggregator?
- Select a Value - Acrisure Alkeme Brown & Brown DAIS/AMWINS HUB ISU Leavitt Group NIIA PIA PIIB SIP United Valley USI Hybrid Other

Agency Contact Information

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• Are you an Agency Principal? *
  Yes No
First Name *
Last Name *
Title *
Email *

Agency Employees

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# of Commercial Lines Producers
# of Personal Lines Producers
# of Dedicated CSR's & Support Staff *

Agency Profile

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• Why would you like to represent Deans & Homer? *
• What Lines of Business does your agency write? *
  Boat & Yacht Boiler & Machinery Builders Risk Business Owners Commercial Marine Commercial Property Commercial Umbrella Difference in Conditions Earthquake Flood General Liability Homeowners Inland Marine Lessors Risk Personal Auto Personal Umbrella Professional Liability Small Commercial Package Surety/ Bonds Surplus Lines Workers Compensation Other
• If other, please describe Lines of Business:
• What Classes of Business does your agency write? *
  Artisan Contractors Automotive/Garages Assisted Living Facilities Building/Business Cannabis Farms/Agriculture Financial Institutions Habitational Hospitality Manufacturers Municipalities Non-Profit Marine Renewable Energy Restaurants Retail Schools Self Storage Facilities Store/Office Technology Trade Contractors Truckers Warehouse Other
• If other, please describe Classes of Business:

Agency Sales

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Total Commercial Lines Annual Premium Volume (rounded whole numbers) *
Total Personal Lines Annual Premium Volume (rounded whole numbers) *
Does your agency have a dedicated Small Commercial Unit? *
Yes No

Top 5 P&C Carriers as of Prior Year End

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1) Carrier Name *
1) Total Written Premium
2) Carrier Name *
2) Total Written Premium
3) Carrier Name *
3) Total Written Premium
4) Carrier Name
4) Total Written Premium
5) Carrier Name
5) Total Written Premium

Is there anything else you would like to tell us about your agency?

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