• Agency Application:
  • * Agency Name:
  • DBA:
  • Street Address:
  • Address Line 2:
  • City:
  • State and ZIP:  
  • * Phone:
  • Fax:
  • Email:
  • State License Number:
  • Non-Resident State-License(ex CA-12345):
  • Type of Agency:
  • Federal I.D.Number:
  • SSN:
  • Year Agency Opened:
  • Volume:
  • Banking Trust Account:
  • Address:
  • Account Number:
  • Affiliate Agency:
  • Affiliate Business:

  • Personnel Data (Include Professional Designation, i.e., CPCU, CLC, CIC:

  • Company Representation Data - Property/Casualty Lines:

  • Most Recent Companies to Leave Your Agency:

  • Most Recent Companies Contracted:

  • Agency Growth Record:
  • 3rd Prior Year:
  • 2nd Prior Year:
  • Last Year:
  • Current Year:
  • Projected Next Year:

  • Expected Volume of Business Rolled Over to the Mercer Insurance Group:
  • Personal Lines:
  • Commercial Lines:

  • Source of Business(%):
  • Walk-ins: Referrals: Solicitations:

  • Other:
  • Primary Form of Advertising:
  • Specialized Line of Insurance:
  • Special Underwriting Authority Form:
  • Restricted Underwriting Program Line:
  • Companies with Claim Draft Authority:
  • Type of Computer:
  • Expectations & General Comments: