Welcome to Louis A. Williams & Associates, Inc.

PRODUCER PROFILE


Address
City
State
Zip Code
Address
City
State
Zip Code
(
 
)
Office #
          (
 
)
Fax #
          (
 
)
Alternate #
Owner/Principal Insurance experience at currrent agency:
(1) Title
Dates
(2) Title
Dates
Insurance experience at prior agencies (indicate positions held and length of time):
(1) Title
Dates
(2) Title
Dates


AGENCY STAFF
Name Position Yrs. @ AGENCY LICENSE(S) HELD LICENSE(S) #

Please list current companies you are appointed with (standard and non-standard).

Company Name Lines Written # of Yrs. Appointed Name of MGA Associated With

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.

COMPANY NAME
REASON FOR TERMINATION

COMPANY NAME
REASON FOR TERMINATION

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Please list all branch offices:
Branch office Address Phone #





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.

FULL NAME
SOCIAL SECURITY # (xxx-xx-xxxx)
DATE OF BIRTH

HOME ADDRESS
HOME PHONE # (555-555-5555)


FULL NAME
SOCIAL SECURITY # (xxx-xx-xxxx)
DATE OF BIRTH

HOME ADDRESS
HOME PHONE # (555-555-5555)


FULL NAME
SOCIAL SECURITY # (xxx-xx-xxxx)
DATE OF BIRTH

HOME ADDRESS
HOME PHONE # (555-555-5555)