What year did your agency start? (ex. 2001) *

Is your agency part of a franchise? *

What is your annual workers' compensation premium? *

Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever been convicted of a felony, had judgment withheld or deferred, or is the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company currently charged with committing a felony? *

Have any demands been made or judgment rendered against the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer? *

Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? *

Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever been subject to a bankruptcy proceedings? *

Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited liability company, ever had their insurance license revoked? *