Owner/Principal Insurance experience at currrent agency:
Insurance experience at prior agencies (indicate positions held and length of time):
Please list current companies you are appointed with (standard and non-standard).
If any company has cancelled your appointment(s) in the last 2 years, please list below the name of the company and a brief explanation of the cancellation.
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Please list all branch offices:
Please complete information below for each and every Owner and/or Principal. If the agency is a corporation, list all officers, directors and/or shareholders.
** THIS FORM MUST BE COMPLETED IN ITS ENTIRETY FOR APPOINTMENT CONSIDERATION.