Grain Dealers Mutual Insurance Company

Prospective Agent Survey
  If you are an agent in IN, MS, NC, OK, TN, VA and would like to know more about how you can become a representative of Grain Dealers Mutual Insurance Company, your completed survey will be submitted directly to the Agency Supervision Department for immediate consideration.

Name of Prospective Agency:
Contact Person:
Street Address:
City:
State: Zip Code:
Phone Number:
E-mail:

Are you wanting to write Commercial Lines? Personal Lines? Both?

Ratio of Personal Lines to Commercial Lines:

Total agency volume: $

Agency's three leading P&C companies: 
Company Name   Total Volume   Loss Experience 
1.
$
%
2.
$
%
3.
$
%

Number of years of insurance experience:
as Owner as Manager

Number of years the agency has been in business:

Professional designations:  CPCU  IIA  CPIW 
CPIA  CIC  LUTC  CLU
Other: 

Professional Associations/Organizations membership:

Errors and Omissions Policy? Yes No

Advertising: Yellow Pages Brochures Other:

Does your agency accept business brokered from any other source? Yes No



 



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