SLS New Agent Profile Sign-Up Please fill out the following form if you are wanting to contract with Graham-Rogers, Inc. as an agent. We will contact you once we have completely reviewed your completed answers. Agency NameAgency Is Owned By:Agency Contact Name* First Last Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Location Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency Phone #Agency Fax #Email Agency Is......Individually OwnedA PartnershipA CorporationHow many employees? (including yourself)Number of years in business under present name?FEIN:During the past 5 years has the agency acquired, merged with another firm, or changed names?NoYesPlease Provide Dates and DetailsAre there any other branch offices affiliated with the agency?YesNoListBranch NameStreet AddressStateZipPhoneFax Please describe how you heard about Standard Line ServicesPlease list all licensed agents operating in your agency.First NameLast Name Who is your Errors & Omissions Carrier?Expiration Date of Agency E&O policy Date Format: MM slash DD slash YYYY Total Premium VolumeTotal Premium Volume Last YearTotal Premium Volume Projected for the Current YearPersonal Lines:Commercial Lines:What other companies/agencies do you currently represent (include MGAs & E&S Brokers)Comapny NamePremium VolumeLoss Ratio Has any company cancelled your agency contract in the last three years?YesNoExplaination for cancelled contractHas a license pertaining to any type of insurance related activity held by you or any employee of the agency or organization ever been revoked, suspended, or withdrawn by any regulatory authority?YesNoPlease explain.
