Thank you for your interest in an appointment with Patriot Select.

To help us get to know you a little better, please complete our application. We want to hear about your agency history, background and current residential market profile.

Once we have reviewed your application, we will contact you to discuss next steps. Please contact us via email at SalesandMarketing@PatriotSelect.com if you have any questions.

Agency Name

DBA

Business Entity Type

Tax ID

Mailing Address

Mailing City

Mailing State

Mailing Zip

Telephone

County

Agency General Email Address (For Policy Correspondence)

Agency Website

Agency Principal First Name

Agency Principal Last name

Agency Principal License Number

Agency Principal Telephone

Agency Principal Email

E&O Carrier Name

E&O Policy Number

Other Agency Contact

Other Contact Telephone

Other Contact Email

Other Agency Contact Title

Home Office Physical Address

Physical City

Physical State

Physical Zip

Name of Agency Group

Other Agency Group

Number of Branch Offices

Number of Licensed Agents

Number of Licensed CSRs

Personal lines policies in force

Mix of Personal Lines Business - Homeowners Please ensure these percentages add up to 100%

Mix of Personal Lines Business - Dwelling Please ensure these percentages add up to 100%

Mix of Personal Lines Business - Auto Please ensure these percentages add up to 100%

Mix of Personal Lines Business - Flood Please ensure these percentages add up to 100%

Current Homeowners (HO3) written premium (month)

Number of new Homeowners policies written (month)

Anticipated Homeowners written premium with Patriot Select

Anticipated new Homeowners policies written with Patriot Select

Current Company Name 1 Who is your top homeowner carrier?

Company 1: Total Written Premium

Company 1: HO3 only Written Premium

Company 1: Overall Approx. Loss Ratio

Add More Companies?

Current Company Name 2 Who is your #2 homeowners carrier?

Company 2: Total Written Premium

Company 2: HO3 only Written Premium

Company 2: Overall Approx. Loss Ratio

Current Company Name 3 Who is your #3 homeowners carrier?

Company 3: Total Written Premium

Company 3: HO3 only Written Premium

Company 3: Overall Approx. Loss Ratio

Which comparative rater do you use?

What agency management system do you use?

Is there potential for a book transfer?

Year Agency Established

Year Present Ownership Established

List any associations that the agency is a member of

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