Klein I S D Proposer Questionnaire

Hallsville ISD Property & Casualty Insurance Proposer Questionnaire

Agency/Co. Name Office Head Address City, State, Zip Phone Fax 800 #

Are you HUB qualified? Web Site: Identify whether agency, direct writer or TPA: Date Founded/Opened Total Number of Local Employees Number of Texas School Clients Number of Commercial Clients

In-House Services – Contact Employee In-House Services – Contact Employee Service Rep - Loss Control - Claim - Other -

Account Executive Backup Executive Name Direct Office Phone E-Mail Address Home Phone Cell Phone Assistant Assistant Direct Phone Assistant E-Mail Address Number School Clients Number Commercial Clients Years with Firm Years in Insurance Designations Previous Experience

References Contact Phone

Agency Name ______Property & Casualty Insurance Companies Requested Service Office Choice Insurance Coverage MGA Premium Loss Ratio (1, 2, 3) Company s

Casualty Only Insurance Companies Requested Service Office Choice Insurance Coverage MGA Premium Loss Ratio (1, 2, 3) Company s

Property Only Insurance Companies Requested Service Office Choice Insurance Coverage MGA Premium Loss Ratio (1, 2, 3) Company s

All premiums shown must be for the servicing office only.