Agency Information

1. Agency Name*
2. Doing Business As

3. Physical Address

   1. Address*
   2. City*
   3. State* AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
   4. Zip*
   5. County/Parish*

4. Mailing/Billing Address

   Same as Physical

   1. Address*
   2. City*
   3. State* AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
   4. Zip*
   5. County/Parish*
5. Agency License Number*
6. Agency Tax EIN Number*
7. Website Address
8. Primary Phone*
9. Primary Fax*
10. Year Established*
11. Organization Type*
    CorporationPartnershipSole ProprietorshipOther

Owner / Principle Information*

Required Contact Information

Additional Contact Information

Agency Affiliations

1. Does your agency belong to any insurance related business organizations or associations? If so, list them below:
3. Does your agency use an agency management system? If so, which one?

Professional Networking

1. Does your agency have a Facebook page? (if yes, what is it?)   
2. Does your agency have a LinkedIn page? (if yes, what is it?)   
3. Do you or your producers/csr's have a professional social media account (Facebook, Twitter or LinkedIn) that is used?
   If yes, what are they listed under?

Agency Production (12 months projected)*

Personal Lines Information

Commercial Lines Information

 For your agency to be considered for commercial authority, please give a detailed description of your agency's experience
 in working specifically with commercial insurance operations below.*

 Have you ever been canceled by another carrier or General Agent / Wholesaler? (If yes, please explain)*

Errors and Omissions

 I authorize the representatives of First Premium^® Insurance Group, Inc. to investigate all statements, references and
 previous companies shown on this application (except as noted) and I agree that I will not hold liable any person(s)
 or company for any truthful answers or opinions expressed by the course of this investigation. I understand that any
 false statements on this record may be cause for disqualification or cancellation.