Insurance Broker Partner Evaluation Request

Insurance Broker Partner Evaluation Request
Please complete this form to help us evaluate your suitability as an insurance broker partner. Provide accurate and detailed information for a thorough assessment.
Company Name
Contact Person Full Name
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Years in Business
Which types of insurance do you offer? (Select all that apply)
Other
Please list all current valid licenses and certifications relevant to your brokerage.
Has your company or any of its principals ever been subject to disciplinary action or regulatory penalties?
If yes, please provide details of disciplinary actions or regulatory penalties.
Which geographic regions do you serve? (Select all that apply)
Other
Please rate your brokerage’s expertise in the following areas:
Rows Personal Insurance Commercial Insurance Claims Handling Customer Service Regulatory Compliance
Excellent
Good
Average
Needs Improvement
Please provide at least two business references (name, company, contact information).
Number of licensed brokers/agents in your company
Briefly describe your business model, areas of specialization, or unique value proposition.
Additional comments or information you wish to provide for this evaluation
Should be Empty:

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