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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:
 Mailing Address is same as business address
Mailing Address:
Mailing City:
Mailing State:
Mailing Zipcode:
Phone (xxx-xxx-xxxx):
Fax (xxx-xxx-xxxx):
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
        L-Life & Health

Are you affiliated with an agency group?    Yes     No

If Yes, which group?
Which Master Agency?

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?