IMO QUICK QUOTE
 
 
 
 
 
 
Name of Agency/Organization*
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Website*
 
 
 
 
Key Contact First Name*
 
 
Key Contact Last Name*
 
 
 
Key Contact(s) Title
 
 
 
 
Email Address*
 
 
Direct Phone (xxx) xxx-xxxx*
 
 
 
Years in Business*
 
 
 
 
 
 
 
Please complete type of products and primary relationships
 
 
 
 
Total Life & Health Revenue ($)
 
 
 
 
 
 
Total Fixed & Indexed Annuities Revenue ($)
 
 
 
 
 
 
Total Variable Annuities Revenue ($)
 
 
 
 
 
 
Total Mutual Funds Revenue ($)
 
 
 
 
 
Total Premium Volume ($)
 
 
 
 
 
 
Total Gross Revenue ($)
 
 
 
 
 
 
Total Net Revenue ($)
 
 
 
 
 
 
Do you provide any additional background check before company appt. or conduct any agent oversight?
 
 
 
 
 
 
 
Are agents appointed directly with the insurance companies?
 
True
False
 
 
 
 
 
 
Total estimated contracted agents?
 
 
 
 
 
 
 
Current Insurance
 
 
 
 
Upload declarations page. If you do not have a declarations page or current coverage, please fill out the information below.
 
 
 
Agency Name
 
 
 
Agency Address
 
 
Agency City
 
 
 
Agency State
 
 
Agency ZIP Code
 
 
 
E&O Insurance Carrier
 
 
 
Effective Date (mm/dd/yyyy)
 
 
Retro Date (mm/dd/yyyy)
 
 
 
Limits
 
 
Deductible
 
 
 
Premium