IMO QUICK QUOTE
Name of Agency/Organization
*
Address
*
City
*
State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
CW Northern Mariana Islands
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Phillippine Islands
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
CW Northern Mariana Islands
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Phillippine Islands
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Agency ZIP Code
E&O Insurance Carrier
Effective Date (mm/dd/yyyy)
Retro Date (mm/dd/yyyy)
Limits
Deductible
Premium