NEW AGENT FORM

This form will give us important information needed to determine if Energi is the right company for your agency. A Corporate Marketing Representative will contact you after receiving your profile.

This form may also be printed out and faxed to 1-978-532-2217

* Indicates a required field
*Agency Name
 *Date
*Mailing Address
 *City
*State
 *Zip Code
*Telephone Number
--		 Fax Number
--
*Email Address
 *How long in business?
Key Agency Personnel
1. *Full Name
 *License Number
*Years Experience
-
(yy)       (mm) 		*Position
2. Full Name
 License Number
Years Experience
-
(yy)       (mm) 		Position
3. Full Name
 License Number
Years Experience
-
(yy)       (mm) 		Position
Annual Premium Volume
*Total Volume All Lines
 *How Many Producers Do You Have?
Top Three Companies Represented
1. *Company Name
 *C/L Volume
*Loss Ratio - 3 year
2. Company Name
 C/L Volume
Loss Ratio - 3 year
3. Company Name
 C/L Volume
Loss Ratio - 3 year
Name and address of bank where premium account is maintained.
*Bank Name
 *Address
*City
 *State
*Zip Code
Approximate Annual Premium Volume You Now Write for Each Category
*Fuel Oil Accounts
 *Propane Accounts
*Gasoline Related Accounts
 *Multi-Fuel Accounts
*Lubricant Accounts
Do you maintain E&O Insurance?
*Yes      No   If yes, please provide a copy of
your E&O declaration page.
Has any company cancelled or refused to renew your E&O policy?
*Yes      No   If yes, why?
Has any company withdrawn from your agency in the past three years?
*Yes      No   If yes, give name of company
and reason.
In which states are you licensed for P/C?
*Hold down your Ctrl key to select multiple states.
What geographical areas will you cover and how do you plan to use and
   market the lines provided by Conifer Energy?
*Explain Below (250 Characters Max)

As part of our normal procedure, a routine inquiry may be made. This inquiry typically concerns information on an applicant's character, general reputation, personal characteristics and business reputation. Futher information on the nature and scope of this inquiry is available to you on written request.

 *"I acknowledge that the above information has been disclosed to me. I hereby declare that all statements made above are true to the best of my knowledge."