An Independent
Property and Casualty
Wholesaler since 1965
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New Producer - Profile Submission Form
  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?
What is the Underwriter’s name, if available and what is the name of the Applicant?  
Company address:
 
City:   State:   Zip Code:  
 
Mailing address:
(If different than above)
City: State: Zip Code:
 
Why did you contact us at this time?:




Other ways: 
 
Type of License:
Bond filed w/ DOI?:
 
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?




  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
Homeowners
Personal Umbrella
Misc. Professional Liability
Other
 
Have you discontinued to do business with any companies or wholesalers?

(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?

(If "yes", explanation full details below)
 
Do you carry Errors & Omissions Coverage?

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)