Confidential Producer Questionnaire

We look forward to learning more about your agency. Please complete the form below to initiate the review process. You can also use this PDF form and email to Jeremiah Howard (jhoward@mwiainsurance.com)


If you have any questions on the report please call Jeremiah Howard at 619.450.1708




AGENCY INFORMATION










Please provide Mailing Address




ADDITIONAL OFFICES
Office #1 Information



Office #2 Information



Office #3 Information



Office #4 Information



Office #5 Information



AGENCY CONTACT








AGENCY ACCOUNTING CONTACT





CONTACT FOR E&O CERTIFICATE REQUESTS



SUB-PRODUCERS
AGENCY WORKERS' COMPENSATION PREMIUM
$
TOP WORKERS' COMPENSATION MARKETS
Carriers with greatest premium volume Appointment (MM/YY) Written Premium ($) 3 Year Loss Ratio
1.
2.
3.
4.
5.
TARGET MARKETS
MIDWESTERN PREMIUM FORECASTS
E&O AGENCY LICENSES




If YES to any questions below, please provide an explanation in the text box or on a separate document and upload it




















VCCA COMPLIANCE CERTIFICATION
 
The federal Violent Crime Control Act, 18 USC 1033 and 1034 ("VCCA"), makes it illegal for any individual or business to engage or participate in the business of insurance if that person has been convicted of violating the VCCA or otherwise has suffered a felony criminal conviction involving dishonesty or breach of trust. It is also illegal to willfully permit another person to engage in the business of insurance if that person is prohibited from doing so under the VCCA. MWIA will provide Producer a copy of the VCCA upon written request.

By initialing the space below, Producer certifies that (1) no principals, agents or employees of Producer have violated any provision of the VCCA by engaging or participating in the business of insurance; (2) reasonable efforts are made by Producer to identify and prevent, on a continuing basis, persons prohibited by the VCCA from engaging or participating in the business of insurance with Producer; and (3) producer agrees to notify MWIA immediately if any person or business with whom Producer participates or engages in the business of insurance who is convicted of any crime covered by the VCCA. 
LEGAL STATEMENT (please provide initials where indicated)
 
If we approve the appointment, please provide a name and email address on where to send the Master Producer Agreement and Program Addendum.


 
I have provided the above information and wish to be considered for appointment. I realize that if all paperwork [Section II] is not submitted, I will not be considered for an MWIA appointment.
 
Principals hereby consent to and authorize MWIA from time to time, to obtain for MWIA’s use, a credit report concerning Principals. Information as to the nature and scope of any investigation(s) will be furnished to the individual upon his/her written request within a reasonable time. 
 
By signing and executing this section, you are providing, on behalf of your agency, your written consent to be sent product updates, information and materials via fax and email by MWIA and its affiliates.

I understand that by providing the fax numbers and email addresses that are listed below or listed on an attached page (as referred to in “Section I. Additional Offices”), I am authorized to and hereby consent for my agency to receive faxes and emails by or on behalf of MWIA. 



AGENCY CONTACT INFORMATION
Authorized Agency Contact Name    Email Address    Department / Title