Producer Questionnaire   

Agency Name:

Street Address:

City:

State

Zip Code:

Phone:

Fax:

Website Address (e.g. www.domain.com):

# of Years in Business (2 year min.)

# of Employees

We are a:

Marketing Department Contact

Marketing Email Address:

Agency Premium Volume:

Agency Specialties:

Percent of Volume in Commercial Market

Percent of Volume in E & S Market:

E&O Policy Information:

Carrier:

Deductible and Limits (1 million min. limit):

Companies You Represent #1

City:

State:

Years Contracted:

Company #2:

City:

State:

Years Contracted:

How did you find out about Gresham & Associates?

Completed by:

Email Address: