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 link to our website to find a fillable PDF Form that you can complete and email to Amy Langley (ALangley@midwesterninsurance.com)

If you have any questions, please call Amy Langley at 678.699.6961

How did you hear about us?

Name of Marketing Representative

Name of person filling out form

E-mail address of person filling out form

AGENCY INFORMATION

Agency Name (Main Office):

Year Established:

Phone Number:

Fax Number:

Main Office Physical Address:

City:

State:

Zip Code:

Years at this address:

Is the Mailing Address same as the Physical Address?

YesNo

Please provide Mailing Address

Address:

City:

State:

Zip/Postal Code:

AGENCY CONTACT

Agency Principal First Name:

Agency Principal Last Name:

Agency Principal Title:

Website:

Agency Principal Name (for mapping)

Agency Contact Name:

Agency Contact Title:

Contact Email:

AGENCY ACCOUNTING CONTACT

Agency Accounting Contact Name:

Phone Number:

Email Address:

Agency FEIN: (Please enter without dash)

Please upload a copy of your W-9:

CONTACT FOR E&O CERTIFICATE REQUESTS

Contact Name:

Phone Number:

Email Address:

SUB-PRODUCERS

Does agency act as a wholesaler or appoint sub production sources?

YesNo

AGENCY WORKERS' COMPENSATION PREMIUM

Total 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

Identify target markets your agency writes:

Average account premium your agency targets:

Average commission received (Percentage):

Number of producers in your agency:

MIDWESTERN PREMIUM FORECASTS

Premium volume your agency hopes to write with Midwestern:

Percentage of premium from new business:

Percentage of premium from existing business:

E&O AGENCY LICENSES

Does the agency have E&O Coverage?

YesNo

Please upload a current E&O certificate:

Does the agency have licenses in all states you write business in?

YesNo

Please upload Agency Licenses in states you plan to write in:

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.

Agency Officer's Initials:

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.

Name:

Email Address:

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.

Agency Officer's Initials:

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.

Agency Officer's Title:

Date:

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 Officer's Name

Agency Officer's Title

Date

AGENCY CONTACT INFORMATION

	Authorized Agency Contact Name	Email Address	Department / Title