AGENCY INFORMATION Agency Name:   Contact:   Mailing Address:   City:     State:   Zip: County:     Telephone: Fax:     Website Address: E-mail Address:   Tax ID:     Agency License#: E&O Insurance Carrier:     E&O Limit: Medical Insurance Carrier:

AGENCY LOCATION Main Location (City/State):   Satellite Offices (City/State):   Agency location:   Single Residence   Apartment   Townhome   Condo   Strip Mall   Multi-Unit Office   Single Occupancy Commercial Building

OWNERSHIP Type of Ownership:   Sole Proprietorship   Partnership   Corporation   LLC Name(s) of Owners Title Years of Experience PL CL Years CL Experience within Agency:   Year Agency Established:     Number of years under current Ownership: Number of people in these Positions:  Producers/Solicitors:   CSR’s:   Other: Check all Designations held within agency:   CPCU   CIC   AAI   CLU   ACSR   CISR Does the agency have ownership in another agency?   No   Yes - Please provide name: Does the agency have ownership in a captive?   No   Yes - Please provide name: Is the agency a member of an aggregator, cluster, alliance, etc?   No   Yes - Please provide name: Automation System(s) used:   Agency is automated for the following function:   Bookkeeping/Rating/Management   Bookkeeping   Rating Only

CARRIERS & PRODUCTION Check carriers you have or have had in the past: Chubb  The Hartford  MetLife  Mid-Continent Republic  Safeco  Travelers   Other(s): Approximately what % is Surplus Lines?  %      Commercial: %      Personal: % Which Carriers(s) is most competitive?   Why are you looking for a new Carrier/Broker?   What New Business commitment can you make? PIF PL CL 1st Year: $ $ $ 2nd Year: $ $ $ 3rd Year: $ $ $ Top 3 Personal Lines Carriers: Written Premium PIF Top 3 Commercial Lines Carriers: Written Premium PIF Total Agency Volume:   Percentage of Volume is:  CL:   PL:   Life/Health:

SALES & MARKETING Check the following that apply to your Agency: Use Lead Generation program Use Telemarketer Have Effective Cross-sell program Have Re-solicitation program Focused on Niche programs Actively Up-sell customers Motivated by Contests/Incentives Sell Small Group P&C Partner with Purchasing Groups

ADDITIONAL INFORMATION What interests you about Common Sense Markets? How did you hear about Common Sense Markets? Referral         Internet         Competitor         Client         Other

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