New Producer Information

We thank you for considering Gresham & Associates.  We ask that all new producers complete an agency questionnaire below.  New producer guidelines include:

• Minimum of 2 years in business.
• Minimum of $2,000,000 in current premium volume.
• Minimum of $1,000,000 in errors & omissions coverage.
• Minimum of 2 standard markets.

If your agency does not meet one or more of the above requirements please contact our marketing department prior to completion of the questionnaire.  If approved, please submit the following additional items within 5 business days:

Agency Questionnaire (complete)
Signed Brokerage agreement
IRS W-9 (completed)
Copy of your agency licenses
Copy of your E&O declarations page evidencing $1,000,000 limits.

Thank you for your interest in Gresham & Associates if you have any questions please contact our marketing department at (888) 473-7442 or marketing@greshaminc.com.

Agency Questionnaire

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Agency Name:
Street Address:
City:
State	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip Code:
Phone:
Fax:
Website Address (e.g. www.domain.com):
# of Years in Business (2 year min.)
# of Employees
We are a:	Single Location Entity Multi Location Entity (i.e. We have branch offices)
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):
Current Contracted Carriers #1:
City:
State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Virginia Wisconsin Wyoming
Years Contracted:
Current Contracted Carriers #2:
City:
State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Virginia Wisconsin Wyoming
Years Contracted:
How did you find out about Gresham & Associates?
Completed by:
Email Address: