THANK YOU FOR YOUR INTEREST IN OUR FACILITIES Already a registered producer click here to Sign-In Please complete and submit the New Producer Profile below. You will receive a phone call from us the next business day. If you have a pending application that needs immediate attention please e-mail it to us using the appropriate E-mail Submission address on the A&M homepage or fax the application to us at 323 255 0957, please indicate "new producer, appointment pending". Required fields are outlined in red   Producer Name: Company Name: DBA (if any): Tax ID: Licensed State: License Number: E-mail:   Business Phone:   Business Fax: Web site address: Date Established:   (if less than 2 years, send resumes of key employees) Are you currently working on a submission with an Underwriter in our office? YesNo What is the Underwriter’s name, if available and what is the name of the Applicant?   Do you have a personal relationship or a relative with anyone working at Anderson & Murison? YesNo If yes, please identify who the person is and the nature of the relationship.   Company address:   City:   State:   Zip Code:     Mailing address: (If different than above) City: State: Zip Code:   Why did you contact us at this time?: Referral of other producer Worked with you in the past Your advertising in Trade Journals Your direct mail, fax or email Other Other ways:    Type of License: AgentBroker Bond filed w/ DOI?: YesNo   Payments to you are made by Electronic Funds Transfer. Please complete so that payments can be made directly to your account. Name of your bank: Routing Number: Account Number: Full Name on Account: Your Accounting Contact Name: Accounting Contact Email: Accounting Contact Phone Number: What Insurance Association(s) do you belong to?: IIABA CAL   American Agents Alliance   WAII  IIABA Other    None   Total number of employees:    Number that are licensed: Key Employees Job Title Email Address Yrs in industry Professional Designation (CPCU, CIC, etc.)   What was your Fire & Casualty premium volume last year? $0 to $500,000 $500,000 to $1 mil $1mil to $5 mil $5mil to $10 mil Over $10 mil   a) What percentage of your volume is:   Commercial Lines  % Personal Lines % Non Standard Auto %   b) Do you accept business from other Retail Producers? If so, what percent of your total volume do you receive from retailers? %   List the top three companies with whom you have a direct Agency Agreement: Name of Company Type of Business Placed Approximate Volume Number of Years   List wholesalers with whom you are presently placing business: Name of Company Type of Business Placed Approximate Volume Number of Years    What percentage of your volume is placed with wholesalers? %   Explain how you choose the wholesaler you use for individual risk placements.   Does your agency have a specialty/niche or marketing program in place?   What type of business do you anticipate placing with A&M? Commercial Accounts YesNo Homeowners YesNo Personal Umbrella YesNo Misc. Professional Liability YesNo Other   Have you discontinued to do business with any companies or wholesalers? Yes No (If "Yes", then state the reasons you discontinued using them):   Has there been any disciplinary action from any Department of Insurance against you or any licensee in your organization? Yes No (If "yes", explanation full details below)   Do you carry Errors & Omissions Coverage? Yes No If yes, please list the name of the company and limits:   Key Contacts: Personal: Name: Extension: Email Address: Commercial: Name: Extension: Email Address: Marketing: Name: Extension: Email Address: Accounting: Name: Extension: Email Address: Is there a preferred email address to send your personal lines documents to?   Name: Email Address: Is there a preferred email address to send your commercial documents to?   Name: Email Address:         (You will get a summary page to review before submtting)