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SAN E-Membership Application Form

1. Application Contact Information

Applicant Name(Required)

Applicant Email(Required)

Agency Name (As Licensed)(Required)

Agency Owner (Enter Primary Owner)(Required)

First Last

Agency Owner Title(Required)

Agency Address

Street Address(Required)

Address Line 2

City(Required)

State(Required)

Zip Code(Required)

Agency Email Address(Required)

Phone Number(Required)

Fax Number

Mobile Number

Website

Is Mailing Address same as above?(Required)

Yes

No

Mailing Address, if not same as above

Street Address(Required)

Address Line 2

City(Required)

State(Required)

Zip Code(Required)

Is Owner Licensed?(Required)

Yes

No

Number of years licensed?(Required)

0-1 Years

1-5 Years

5-10 Years

10 or more Years

2. Additional Agency Principals

Do additional Agency Principals exist?(Required)

Yes

No

Principal Name

First Last

Principal Title

Principal Name

First Last

Principal Title

Principal Name

First Last

Principal Title

3. Agency Profile

Date Established(Required)

MM slash DD slash YYYY

Total Premium Volume (If start-up agency, enter 0)(Required)

4. Mix of Business Estimated Percentage (equal 100%)

Total of business lines must equal 100%

Personal

Commercial

Benefits

Life

Other

Total (Sum of all Business Lines should be 100%)(Required)

5. Insurance

Does your Agency carry Errors and Omissions Insurance?(Required)

Yes

No

Does your Agency carry Cyber Liability Insurance?(Required)

Yes

No

6. Top Carriers

Carrier 1

Carrier 1 Premium

Carrier 1 Loss Ratio

Carrier 2

Carrier 2 Premium

Carrier 2 Loss Ratio

Carrier 3

Carrier 3 Premium

Carrier 3 Loss Ratio

Carrier 4

Carrier 4 Premium

Carrier 4 Loss Ratio

Carrier 5

Carrier 5 Premium

Carrier 5 Loss Ratio

Carrier 6

Carrier 6 Premium

Carrier 6 Loss Ratio

Carrier 7

Carrier 7 Premium

Carrier 7 Loss Ratio

Carrier 8

Carrier 8 Premium

Carrier 8 Loss Ratio

Carrier 9

Carrier 9 Premium

Carrier 9 Loss Ratio

Carrier 10

Carrier 10 Premium

Carrier 10 Loss Ratio

7. Changes in Carrier Representation

Have you added new carriers or been terminated by any carriers in the last 5 years?(Required)

Yes

No

Co 1 Carrier(Required)

Co 1 Carrier Action(Required)

Co 1 Reason, if Terminated(Required)

Co 2 Carrier

Co 2 Carrier Action

Co 2 Reason, if Terminated

Co 3 Carrier

Co 3 Carrier Action

Co 3 Reason, if Terminated

8. Personnel Profile

Are you and/or your staff familiar with ACORD applications, and do you know how to complete them?(Required)

Yes

No

Do you consider yourself and/or your staff proficient in personal lines and products and coverage forms?(Required)

Yes

No

Do you consider yourself and/or your staff proficient in commercial lines and products and coverage forms?(Required)

Yes

No

Do you understand that we would expect you to routinely review business placed with our carriers and to re-underwrite risks if a problem area/line of business develops?(Required)

Yes

No

Please describe sources of continuing and ongoing professional education for you and/or your staff.

Have you ever had a license for any professional designation placed on probation, denied, suspended, revoked, canceled or non-renewed by any state or regulatory body?(Required)

Yes

No

Have you ever been disciplined, fined or censured by state insurance department, and regulatory department or court?(Required)

Yes

No

Have you filed for or been discharged from any bankruptcy during the past five years? (Required)

Yes

No

Have you ever been an owner, partner, officer or director of an insurance agency that would answer yes to any of the above?(Required)

Yes

No

Have you or one of your employees ever been convicted of a criminal activity? (Required)

Yes

No

9. References

Reference 1, Name(Required)

First Last

Ref 1 Title(Required)

What is your association to this Reference?(Required)

Ref 1 Phone Number(Required)

Ref 1 Mobile Number

Reference 2, Name(Required)

First Last

Ref 2 Title(Required)

What is your association to this Reference?(Required)

Ref 2 Phone Number(Required)

Ref 2 Mobile Number

10. General Information

Applicant has more than two (2) years prior experience in the business of selling and servicing insurance products and services?(Required)

Yes

No

Applicant is relying on a current director or officer with more than two (2) years management experience in business.(Required)

Yes

No

Officer or Director with Required Experience

Please provide current directors or executive officers with more than two (2) years management experience in business.

Name(Required)

First Last

Title(Required)

Agency Name(Required)

Email(Required)

Phone Number(Required)

Mobile Number

Type of Business(Required)

Property/Casualty

Life, Health, Financial Services

Experience in Years and Months (e.g. 4.2 = 4 years, 2 months)(Required)

11. Financial Information

Please provide your prior calendar year income generated by all insurance and financial services (If start-up agency, enter 0):(Required)

12. Recruiter

Recruiter you are working with?(Required)

If Recruiter = Other, please include Recruiter name

SAN E-Membership Application Form

Your changes have been saved. Please review the application at the following link:

https://www.sangroup.com/member-application/san-e-membership-application-form/?guid=82EC5A06-03FD-4C8A-BF09-FDDCCA7A7A6D

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Hampton, NH 03842

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