New Producer Profile

Step 1 of 2: Submit

Thank you for your interest in our facilities. Please complete the new producer profile. You will receive a phone call from us the next business day. if you have a pending application that needs immediate attention please e-mail it to us using the appropriate E-mail Submission address on the homepage or fax the application to us at 323.255.0957, please indicate "New Producer, appointment pending".

Producer Name: Company Name: DBA (if any): Tax ID: Licensed State: License Number: E-Mail Address: Business Phone: Business Fax: Website address: Date Established: ( If less than 2 years, send resumes of key employees)

Are you currently working on a submission with an Underwriter in our office? If yes, what is the Underwriter's name, if available and what is the name of the Applicant? Do you have a personal relationship or a relative with anyone working at Monarch E&S? If yes, please identify who the person is and the nature of the relationship. Company address: Mailing Address: (If different than the above) Why did you contact us at this time?: Other ways: Type of License: Bond filed w/ DOI?: What Insurance Association(s) do you belong to?: Total number of employees: Number that are licensed: Please list Key Employees, Job Title, Email Address, Yrs in Industry and Professional Designation (CPCU, CIC, etc.) What was your Fire & Casualty premium volume last year?: What percentage of your volume is: (Commercial, Personal Lines & Non Standard Auto) Do you accept business from other Retail Producers? If so, what percentage of your total volume do you receive from retailers? List the top three companies with whom you have a direct Agency Agreement: (Name of Company, Type of Business Placed, Approx. Volume & Number of Years) List wholesalers with whom you are presently placing business. (Name of Company, Type of Business Placed, Approx. Volume & Number of Years) What percentage of your volume is placed with wholesalers?: Explain how you choose the wholesaler you used for individual risk placements. Does your agency have a specialty/niche or marketing program in place?: What type of business do you anticipate placing with Monarch E&S?: (Commercial Accounts, Homeowners, Personal Umbrella, Misc. Professional Liability & Other) Have you discontinued to do business with any companies or wholesalers?: Have you discontinued to do business with any companies or wholesalers?: If yes, then state the reasons you discontinued using them. Has there been any disciplinary action from any Department of Insurance against you or any licensee in your organization?: If yes, explanation full details below.: Do you carry Errors & Omissions Coverage?: If yes, please list the name of the company and limits:

Key Contacts:

Personal Lines: (Name, Phone Number & E-Mail Address) Commercial Lines: (Name, Phone Number & E-Mail Address) Marketing: (Name, Phone Number & E-Mail Address) Accounting: (Name, Phone Number & E-Mail Address)

Is there a preferred email address to send your personal lines documents to?: Is there a preferred email address to send your commercial lines documents to?