ASSOCIATED MUTUAL INSURANCE COOPERATIVE THANK YOU FOR

ASSOCIATED MUTUAL INSURANCE COOPERATIVE THANK YOU FOR
11 PREVALENCE OF POTENTIAL DRUGDRUG INTERACTIONS AND ITS ASSOCIATED
3117 APPROVAL LIST (ASSOCIATED EQUIPMENT) PBT’S OR PAST DEVICES

A HIGH EXPRESSION RATIO OF RHOARHOB IS ASSOCIATED WITH
A POLICY FOR SUPPORTING EMPLOYEE VOLUNTEERING AND ASSOCIATED MANAGERS
ADPD 2017 WORKSHOP BASIC NEUROPATHOLOGY OF AGEASSOCIATED NEURODEGENERATIVE

Agency Information Form

ASSOCIATED MUTUAL INSURANCE COOPERATIVE THANK YOU FOR

Associated Mutual Insurance Cooperative


Thank you for your interest in becoming an Agent with
Associated Mutual Insurance Cooperative.

If you are a licensed property/casualty producer and would like to explore a relationship with us, please complete the Agency Information Form below.

The completed questionnaire should be forwarded to:

Associated Mutual Insurance Cooperative
Attention: Marketing
P.O. Box 307
Woodridge, NY 12789

Or, you may email or fax it instead.

Email: [email protected]
Fax: 845-434-5430


ASSOCIATED MUTUAL INSURANCE COOPERATIVE THANK YOU FOR

Associated Mutual Insurance Cooperative

Woodridge, NY 12789

Phone: 845-434-4550 Fax: 845-434-5430

www.associatedmutual.com

Agency Information Form

Date Completed:      

Region No:      

Agency Name:      

Location Address:

     

Mailing Address:

     

Telephone:      

Fax:      

Agency Email Address:

     

Website Address:

     


Corp. Individual Partnership TBA


SSN:      

Federal ID:      

Established:      


Banking Reference: Name:      

Branch:      

Address:      



P&C License:      

(Attach copy of current license)

If an Individual, Date of Birth:      



Name of Agent’s E&O Carrier:      

(Attach current copy of Declarations page)

Policy No:       Policy Period:      



Do you ever accept Brokered Business, or have a working arrangement with any outside brokers?


If yes, explain:     



Key Personnel


Principal or Officer

Title

Licensed?

How Long?

Email

Accounting

     

     

     

     

     

     

     

     

     

     

     

     

Claims

     

     

     

     

     

     

     

     

     

     

     

     

Commercial Lines

     

     

     

     

     

     

     

     

     

     

     

     

Personal Lines

     

     

     

     

     

     

     

     

     

     

     

     



Total Agency P.C. Volume (Last full year):      

% Personal:       % Commercial:     

Direct Bill:       Agency Bill:      


Companies Represented

Name

Current Annual Premium

Loss Ratio

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Has Agency ever been terminated by a company?

If yes, by whom and for what reason(s)?      


Does Agent represent a U.R.B Affiliated Company?

If yes, list below:


Name

Current Annual Premium

     

     

     

     

     

     


Attach 3 years yearend production experience reports for all companies.


Region No:      

Agent’s Code Assigned:      

Binding Code:      

Agt-1 to Department:      



AGEING CAUSES PROMINENT NEUROVASCULAR DYSFUNCTION ASSOCIATED WITH LOSS OF
AGREEMENT PERFORMANCE BOND ASSOCIATED WITH AGREEMENT
AGREEMENT FOR HIRE OF STEAM WEED AND ASSOCIATED EQUIPMENT


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