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Scobie Group® —Agency Questionnaire

(Please complete a questionnaire for each office location beginning with primary location)

All Fields Are Required.

Agency Name:

DBA Name (If Any Or ReEnter Business Name):

Federal ID#:

Business Type:

If Other, What Kind Of Business Is This:

Location Address:

City:

State:

Zipcode:

Mailing Address is same as business address

Mailing Address:

Mailing City:

Mailing State:

Mailing Zipcode:

Phone (xxx-xxx-xxxx):

Fax (xxx-xxx-xxxx):

Website:

Do you have other locations to complete a Questionnaire for? Yes No

If Yes, do you want a separate broker code for production and policy issuance at each location? Yes No

How did you hear about Scobie Group:

Which Employee?

Which Agent?

Which Industry Association?

Where did you see our ad?

Please Explain:

Agency Principals:

Name	Title	%Ownership	Email Address	Phone
		%
		%
		%

Agency Accounting Contact:

Name	Title	Email	Phone

Producers & Staff Members:

Name	Title	Focus	Email Address	License #










	Key: C-Commercial P-Personal L-Life & Health F-Farm

Are you affiliated with an agency group? Yes No

If Yes, which group?

Which Master Agency?

SIAGL
MIAA
BRAN
MSAA
NIAA
SIAAZ
UAI
MEAA
VIAA
UIAA
AHA
Other

List Group Name:

Do You Maintain Fidelity Coverage Over All Officers And Employees? Yes No

Company Name:

Limit:

Do You Maintain E&O Coverage? Yes No

Company Name:

Limit:

Expiration Date:

Do You Use A Comparison Rater To Compare Quotes? Yes No

If Yes, Which One?

Do you use an agency management system? Yes No

If Yes, Which One?

What media do you use to advertise?

Please Explain:

Are you a member of any industry associations?

Please Explain:

Are You Interested In Becoming An Agent For Farm Related Risks? Yes No

Approximate Annual Volume Of Farm Business

Carrier	Volume	$
Carrier	Volume	$
Carrier	Volume	$

Does Your Agency Specialize In Commercial Transportation Exposures Placed With Wholesale Brokers? Yes No

Wholesale Broker	Annual Volume	$
Wholesale Broker	Annual Volume	$
Wholesale Broker	Annual Volume	$

Does Your Agency Have A Class Of Business Or Industry A Producer Will Target
Or Focus On? Yes No

Please Enter The Class Of Business Or Industry A Producer Will Target

Are There Any Other Questions Or Comments You Have?