HGA Agency Questionnaire - Heartland General Agency, Inc.

Agency Questionnaire

If you wish to pursue a contract with HGA, please complete the form below. All required fields are indicated with a red asterisk (*).

Agency Name*

Mailing Address

Street Address*

City*

State*

Zip Code*

Street Address

Same as mailing address?*

Yes

Street Address*

City*

State*

Zip Code*

Email Address*

Phone Number*

Fax Number*

Agency Details

Principal(s) Name*

Home Address*

City*

State*

Zip Code*

Email Address*

Social Security# or Taxpayer ID#*

OAIA Member?

Yes

Date Established

Present Ownership Since

Agency Entity Type*

Corporation

Partnership

Individual

Total Agency Volume

Personal Lines %

Commercial %

Projected Volume

E & O Dec Page and Agency License(s)

E & O Carrier

Policy #

Expiration Date

Upload a copy of the E & O Dec Page and Agency License(s) (PDF files only)

Maximum file size: 314.57MB

Licensed Individual(s)

Complete all of the fields below for each licensed individual in your agency, then click the button titled "Add" to add other individuals.

Name*

Email Address*

License #*

Principal of Agency?*

Yes

Add Remove

Upload a copy of each listed license above (PDF files only)*

Maximum file size: 314.57MB

Key Agency Personnel

Accounting

Name

Title

Phone Number

Email Address

Add Remove

Commercial Lines

Name

Title

Phone Number

Email Address

Add Remove

Personal Lines

Name

Title

Phone Number

Email Address

Add Remove

List of Companies Currently Represented

Company Name

How many years?

Add Remove

List of General Agencies Currently Represented

Company Name

How many years?

Add Remove

Signature*

NOTE: Please type whatever you would write on a physical contract if signing it by hand.

Application Submitted

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