Register - Agency

Agency General Information

Does your agency have any satellite offices?

If yes, please attach a list of all satellite offices including addresses and main contact person on the next page.

Does your agency broker Workers' Compensation coverage for other agencies?

Agent Contact Information

Primary Agency Contact.

Please state the Agency Administrator. The Agency Administrator will manage agency users, dispense Midwest downloads and documents to appropriate personnel and have access to commissions as well as all submissions.

Agency Principals.

Include each Name and Percentage of Ownership.

Please attach a list of commercial line producers and account managers on the following page.

Agency Volume Information for Workers' Compensation

What is your agency's total workers' compensation volume? Please include both mono-line workers' compensation carriers and multi-line carriers.

What is your agency's total workers' policy count? Please include both mono-line workers' compensation carriers and multi-line carriers.

Please List Total Workers' Compensation Volume by Carrier:

Carrier Name

Premium Volume

Policy Count

Loss Ratio

Disclosures

Do all agents selling and marketing business for the agency have a current producer's license?

Has your agency ever been the subject of a bankruptcy, receivership or similar proceeding?

Has any owner, officer, director, partner, employee or solicitor of the agency ever been the subject of a disciplinary action by any insurance authority?

Has there been an errors and omissions claim made against the agency or any of its employees, principals, (past or present), within the last 5 years?