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Broker Profile

Company Name:    Principal/Owner:
E-Mail Address:    Phone Number:
Year Business Established:    Number of Employees:
How is your Brokerage Licensed (I.E. Agent, Broker, Excess & Surplus Lines Broker)?
Premium Volume Distribution Current Year Prior Year
Commercial Auto
Public Auto (Livery)
Workers Compensation
List Major Companies/Wholesalers You Represent in Order of Premium Volume:
Name Annual Premium Line of Business Commission
Has Your Account With Any Company Been Suspended or Terminated?
Company :   Reason :  

Has Your Brokerage or any of its Owners, Principals, Partners or Employees Had a Company or Individual License Suspended or Revoked?
If Yes, Please Give Details :

Has Your Brokerage or any of its Owners, Principals, Partners or Employees Had any Disciplinary Action by a State Insurance Department or Other Regulatory Authority?
If Yes, Please Give Details :  

Has Any Principal, Owner or Partner Been Convicted of a Crime?
If,Yes Give Details :  

Is There Any Pending, Threatened, or in the Last Five Years, any Litigation or Judgments Exceeding $10,000 Against the Brokerage or Any of the Principals?
If,Yes Give Details :  

Has Your Brokerage or any Principal, Owner or Partner Ever Filed for Bankruptcy or Re-Organization Under Bankruptcy Law?
If,Yes Give Details :  

Have you or Your Brokerage Been Party to Any Errors and Omissions suit in the Last Five Years:
If,Yes Give Details :  

I hereby affirm, under the penalty of perjury, that the information provided in the application is true and accurate. Maya Assurance Company Conducts Background Checks on all Brokerages, their Owners, Principals and Partners. Your Signature Below Authorizes Maya Assurance Company to Conduct Such an Investigation.

Signature Name (print)
Title Date (MM/dd/yyy)