Become a Utica National P&C Agent - Questionnaire

To continue with the process to become a Utica National P&C Agent, please take a few moments to fill in some information so we can learn more about you and your agency. (Note: Required fields are indicated in * bold red.)

Agency Name & Contact Information
* Agency Name:
* Street Address:
* City:

* State:

* ZIP Code:
* Telephone:
ext. (xxx)xxx-xxxx
Fax:
(xxx)xxx-xxxx
Web Address:
* Required:
Key Contact Information
* First Name:
* Last Name:
* Title:
* E-mail Address:
* What is 6+6?
(To make sure you're a person)

Licensing and Production Information
* Years Agency has been in Business:
* Number of Licensed Producers:
* Number of Licensed CSRs:
* List other Carriers you Represent:



* Target Markets: Below is a listing of our Personal and Commercial Lines product offerings. Please select the target markets that you work with that could be placed with Utica National. Select all that apply.

* Personal Lines

Automobile Boat Homeowners
Identity Theft Motorcycle Snowmobile
Tenants Umbrella None

* Commercial Lines

Auto Service Business Bakeries Bed & Breakfast
Bonds Child Care Centers Contractors
Educational Institutions Energy Dealers Financial Institutions
Franchised Auto Dealers Funeral Homes General Business
Libraries LIght Manufacturing Machine Shops
Non-Franchised Auto Dealers Printers & Graphic Arts Industries Professionals
Religious Institutions Vendors/Wholesalers/Distributors Volunteer Fire Departments
None    
Personal Lines Total Premium:
Please list your top three Personal Lines carriers and total premium volume.
Carrier Name: Premium:
1. $
2. $
3. $
 
Commercial Lines Total Premium:
Please list your top three Commercial Lines carriers and total premium volume.
Carrier Name: Premium:
1. $
2. $
3. $
 
Thank you for taking the time to complete this information. If you have any other comments, please feel free to add them below:


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