Evolution Partners Membership Application

step 1

step 2

step 3

General Information

Your name

I am a principal/owner of the agency

Yes

Agency name (as it appears on licenses)

DBA (if applicable)

Website address

Legal entity

Mailing address

City

State

ZIP

Physical address (if different than mailing)

City

State

ZIP

Email address

Phone

Fax

Federal tax ID number

Number of years in business

Agency license number

E&O carrier

E&O policy number

E&O liability limits

E&O expiration date

Carrier & production information

Total agency annual premium volume

Number of producers

Number of CSR’s

Total personal lines annual premium volume

Total commercial lines annual premium volume

Carriers represented

Name of carrier

Direct appointment

Wholesaler/MGA

Estimated annual premium volume

Estimated quotes per month

Type of carrier

Commercial

Personal

Both

Would you like to move to Evolution?

Yes

Carriers needed

Name of carrier

What target industries or areas of speciallzation do you need this carrier for?

Estimated annual premium volume

Estimated quotes per month

Type of carrier

Commercial

Personal

Both

Agency technology

Agency management system

Comparative rating system(s)

Other sales and marketing systems used (crm, lead generation, marketing automation)

Premium finance companies used

Agency business plan

Areas of specialization in your agency

Any areas that you would like to target or specialize in (with the right carriers)?

How can membership in Evolution help your agency grow?

Premium finance companies used

Agency business plan (continued)

How does your agency generate new business?

How much do you plan to grow your agency this year? (%)

Do you advertise? If so, what type of advertising does your agency do?

Does your agency telemarket or invest in lead generation?

Do you belong to any associations?

Do you currently have any program business or have plans to pursue in the near future?

Do you plan on hiring producers or adding to your sales force?

Additional initiatives and growth plans:

Premium goals

1st year

Projected quotes per month

Average written premium per policy

Projected number of policies issued monthly

2nd year

Projected quotes per month

Average written premium per policy

Projected number of policies issued monthly

3th year

Projected quotes per month

Average written premium per policy

Projected number of policies issued monthly

Thank you for choosing to apply for Evolution Partners Membership

We appreciate your interest in our community and look forward to reviewing your application.