Associated Mutual Insurance Cooperative
Thank you for your interest in becoming an Agent with
Associated Mutual Insurance Cooperative.
If you are a licensed property/casualty producer and would like to explore a relationship with
us, please complete the Agency Information Form below.
The completed questionnaire should be forwarded to:
Associated Mutual Insurance Cooperative
Attention: Marketing
P.O. Box 307
Woodridge, NY 12789
Or, you may email or fax it instead.
Email: [email protected]
Fax: 845-434-5430
Associated Mutual Insurance Cooperative
Woodridge, NY 12789
Phone: 845-434-4550
Fax: 845-434-5430
www.associatedmutual.com
Agency Information Form
Date Completed:
Agency Name:
Location Address:
Region No:
Telephone:
Agency Email Address:
Fax:
Website Address:
Mailing Address:
Corp.
SSN:
Banking Reference:
Individual
Federal ID:
Partnership
TBA
Established:
Name:
Branch:
Address:
P&C License:
(Attach copy of current license)
If an Individual, Date of Birth:
Name of Agent’s E&O Carrier:
(Attach current copy of Declarations page)
Policy No:
Policy Period:
Do you ever accept Brokered Business, or have a working arrangement with any outside brokers? Select...
If yes, explain:
Key Personnel
Principal or
Officer
Title
Licensed?
How Long?
Email
Select...
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Accounting
Claims
Commercial
Lines
Personal
Lines
Total Agency P.C. Volume (Last full year):
% Personal:
Direct Bill:
% Commercial:
Agency Bill:
Companies Represented
Name
Current Annual Premium
Loss Ratio
Has Agency ever been terminated by a company? Select...
If yes, by whom and for what reason(s)?
Does Agent represent a U.R.B Affiliated Company? Select...
If yes, list below:
Name
Current Annual Premium
Attach 3 years yearend production experience reports for all companies.
Region No:
Binding Code:
Agent’s Code Assigned:
Agt-1 to Department: