Wufoo

2008 Top P/C Agencies Entry Form

Is Yours a Top 100 Property/Casualty Independent Agency?

Find out by submitting your entry for the 2008 Insurance Journal Top
Property/Casualty Agencies Listing.

Now, three ways to qualify: Top Overall Independent Agencies, Top Commercial Lines Independent Agencies, Top Personal Lines Independent Agencies.

Join the ranks of the industry leaders among privately-held retail independent insurance agencies by completing this quick survey for the 2008 Insurance Journal Top 100 P/C Independent Agencies listing.

Take pride in what you and your agency have accomplished. Be recognized as an industry leader among private insurance agencies. Be recognized for overall sales as well as for Commercial Lines and Personal Lines sales.

Submit your independent agency profile today and watch for the first results beginning in the April 21, 2008, issue of Insurance Journal. The deadline for entries is April 4, 2008. Results may also be faxed to 1 619-584-1200. Simply fill out the form below and click "Submit."

If you would like to advertise in this issue, please contact Julie Tinney at 1 (619) 584-1100 x 148 or e-mail Julie Tinney

If you have any questions or problems submitting this form, please E-mail Andrea Wells.

This survey is for privately-owned, retail, property/casualty independent insurance agencies.

Please note: Any field with an asterisk (*) is required.

Certain fields are REQUIRED before the form can be submitted. If the form fails to submit, please review it for empty fields that may be needed.
Contact Name: * Title First Last Suffix
Contact E-mail: *
Agency Name: *
Main Office City: *
Main Office State:
Zip Code:
Phone: - (###) - ### ####
Fax: - (###) - ### ####
Website: *
Total Number of Employees: *
Number of P/C Insurers Represented: *
Agency Principals:
Does your agency specialize in any particular market segment, i.e., construction, professional liability, etc.?
Yes No
If so, what is it?
Has your agency merged with another agency or acquired any agencies in 2007?
Yes No
If so, please provide the names of the companies merged/acquired?

name 1, name 2, name 3
Is your agency affiliated with a network or cluster?
Yes No
If yes, name of affiliated group:
Is your parent company a: (Please check all that apply and include the name as well)
Bank Wholesaler Insurance Company Other N/A
Parent company name:
2007 * Please enter all numbers as figures, i.e., 5400000
2007 Total P/C Premiums Written: * $ . Dollars Cents
2007 Total Commercial Lines P/C Premium: * $ . Dollars Cents
2007 Total Personal Lines P/C Premium: * $ . Dollars Cents
2007 Other than P/C Premium: $ . Dollars Cents
2007 * Please enter all numbers as figures, i.e., 5400000

Revenues defined as (P/C commissions, fees, profit sharing, contingent commissions, other P/C revenue)
2007 P/C Revenues: $ . Dollars Cents
2007 Commercial Lines P/C Revenue: $ . Dollars Cents
2007 Personal Lines P/C Revenue: $ . Dollars Cents
2007 Other than P/C Revenue: $ . Dollars Cents
Feel free to contact us for more information on our agency's success story:
Yes No
Additional states (if any) in which your agency has offices:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Do Not Fill This Out