Agency Appointment Questionnaire

Agency Appointment Questionnaire1Ed 1-29-16 Phone Agency is a:IndividualPartnershipExact IRS Corporate NameCity:ZIP:Mailing Address:Other locations? NoYes - If yes how many?_____Name: (First, MI, Last)Officer Title:(Pres, VP, etc.)Email address:List all Agency owners and officers Primary Owner s Information Home Address E-mail addressFax County OtherC CorporationS CorporationLLCA gency Main Email addressDate: Agency DBA Name Agency Website AddressStreet AddressCityPhoneComplete and return to: Marketing Department, Florida Specialty Insurance Company by email If you have any questions please call (888) 723-3055 ext 4. Use a separate Agency Appointment Questionnaire for each additional Cattleridge Blvd #101, Sarasota, FL 34232(888) 723-3055 ext 4 Marketing Email: Trust/Estate Federal ID#CityStateZip2Ed 1-29-16 Licensed 2-20 Agents at this Location: Agent in Charge *License #EmailAgent #EmailAgent #EmailAgent #EmailPLEASE ENTER CONTACT INFORMATION BY DEPARTMENT FOR ANY NON-LICENSED REPRESENTATIVESName: (First, MI, Last)Title PositionDepartmentPhone NumberEmail AddressCopy of E&O Policy Dec Page Prepared by:_____Title:_____Phone Number: _____Email Address:_____Agency Appointment Questionnaire5971 Cattleridge Blvd #101, Sa

Revised 09/2015 1 . FLORIDA SPECIALTY MANAGING GENERAL AGENTS, LLC . Agency Agreement. This AGREEMENT is entered into as of _____ by and between

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