Please complete the information requested below. We have requested this information so we can better understand who we are doing business with and how we can best provide products and services available

Name of Agency:
Contact Person:
Street Address:
City: State: Zip:
Telephone Number: Fax Number:
Web Address Email Address:
Agency Premium Size: Personal Lines: Commercial Lines:
Total No. of Employees: No. of Salespeople: No. of Office Locations:
Principals
 
Year Established:
Tax ID Number:
How did you hear about First Cardinal?
For what industry(ies) are you interested in Workers' Compensation coverage?
 

Do you specialize in any fields or vocations?
  if YES which one
Are you familiar with the Texas Mutual Safety Groups?
  if YES which one(s)
Have you place any business with TM Safety Groups?
  if YES which one(s)
Have you place any business with any other Self-Insured Groups before?
  if YES which one(s)
What are your top 3 workers' compensation markets (including Self-Insurance)?
1.)
2.)
3.)