Prospective Agency Questionnaire "*" indicates required fields Step 1 of 7 14% Prospective Agency Questionnaire Thank you for applying for an agency appointment with Tower Hill Insurance Group. The Tower Hill Family of Companies specializes in property insurance for both personal lines and commercial lines. Tower Hill Insurance has been offering competitive products exclusively through our agency partnerships since 1972. Tower Hill is headquartered in Alachua, Florida and also has offices in the following locations: in Palm Beach, Florida; Lexington, Kentucky; Loveland, Ohio; and Dallas, Texas. Currently, Tower Hill writes business in these states: Alabama, Arizona, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. If you are interested in representing Tower Hill Insurance, please complete this prospective agency questionnaire (PAQ). Please note that product availability is currently limited in some states.For what type of agency are you applying?* Independent Agency Captive Agency For what line(s) of business are you applying?* Personal Lines Commercial Lines In which state(s) are you looking to write business?* Alabama Arizona Florida Louisiana Mississippi North Carolina South Carolina Tennessee Texas Select AllIn which state(s) are you looking to write business?* Alabama Florida Georgia South Carolina Texas Select AllThis field is hidden when viewing the formTHIG Personal Lines Lead? true This field is hidden when viewing the formTHIG Commercial Lines Lead? true This field is hidden when viewing the formTower Hill Specialty Lead? true This field is hidden when viewing the formPL StatusThis field is hidden when viewing the formCL StatusDo you have a physical location in Florida?* Yes No Agencies seeking an appointment to write business in Florida must have a physical location in the state.Agencies seeking an appointment to write business in Florida must have a physical location in the state. General Agency InformationAgency Name: (as indicated on W9)DBA Name*The agency name you provide here will be printed on all policy documents and used in Tower Hill marketing materials and channels, such as the Agency Search feature on Tower Hill's website.Location Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency Phone NumberTax or Federal IDCurrent # of EmployeesAgency Website URLAgency Facebook URLAgency Twitter URLAgency E-Mail Address Year Established*Do you have a current Personal Lines appointment with Tower Hill? Yes No Do you have a current Commercial Lines appointment with Tower Hill? Yes No What is your Tower Hill agency number?Has the agency had a prior appointment with Tower Hill Insurance Group? Yes No Are you a sub-producer of a Managing General Agency (Wholesaler)? Yes No What is the name of the MGA?Has any company terminated the agency within the past three years? Yes No If YES, please explain in detail in the space provided below.Ownership of Book? Agency Producer Combination Other Are you buying a current Tower Hill book of business? Yes No Please provide the name of the agency from whom you are buying the book of business.If available, please provide the Tower Hill agency number (e.g., FL1234) for the agency from whom you are buying the book of business.If available, please upload a copy of your buy/sell agreement.Max. file size: 80 MB. Has the agency or any officer, owner, or partner ever been charged, arrested, or convicted of a felony? Yes No If yes, please provide a detailed explanationHas the agency or any officer, owner, or partner ever had an insurance license be denied, suspended, or revoked? Yes No If yes, please provide a detailed explanationHas the agency or any officer, owner, or partner ever been disciplined by an insurance regulatory body? Yes No If yes, please provide a detailed explanationHas the agency or any officer, owner, or partner ever filed bankruptcy, been sued, or had a judgment entered? Yes No If yes, please provide a detailed explanationHas the agency or any officer, owner, or partner ever had any bond contract cancelled for cause? Yes No If yes, please provide a detailed explanationHas the agency or any officer, owner, or partner ever had any agency contract cancelled for cause? Yes No If yes, please provide a detailed explanationAgency CoveragesE&O CarrierE&O Policy NumberE&O Policy LimitPlease upload a copy of your agency's E&O policy*Max. file size: 80 MB. AGENCY PRINCIPAL:Principal Name First Last Email Enter Email Confirm Email Principal's Insurance License NPNHow many locations does your agency have?123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100+ Standard commercial companies agency presently representsList commercial companies with whom agency is currently writing.List commercial companies with whom agency is currently writing.Company NameDate AppointedIn-Force Premium Add RemoveEstimated Commercial BusinessHOA/COA*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveOffice/Retail*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveCommercial Residential*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveHotel/Motel*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveSelf Storage*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveMobile Home Park*Est. Premium ($)Est. Mix of Business (%)Source Add RemoveESTIMATED TOTAL PRODUCTION: Annual estimated new business production with Tower Hill*Please estimate the volume your agency will write with Tower Hill annually for each line of business. You may indicate as total premium. HOA/COAOffice RetailCommercial ResidentialHotel/MotelSelf StorageLessor's RiskMercantile Advantage/Mainstreet BOP Current Premium Volume and ProductionUse whole numbers only. Do not include $ or % signs.Current Total In-Force PremiumCurrent Total In-Force Personal Lines PremiumWhat are your top three lines of business? Add RemoveWhat are your top three states? Add RemoveWhat percentage of your current book of business is Personal Lines?Who are your top three Personal Lines carriers? Add RemoveWhat percentage of your current book of business is Commercial Lines?Who are your top three Commercial Lines carriers? Add RemoveCurrent Homeowners In-Force PremiumWho are your top three Homeowners carriers? Add RemoveCurrent Condo In-Force PremiumCurrent Mobile Home In-Force PremiumWho are your top three Mobile Home carriers? Add RemoveCurrent Dwelling Fire In-Force PremiumWho are your top three Dwelling Fire carriers? Add RemoveCurrent Flood In-Force PremiumCurrent Personal Auto In-Force PremiumHow many homeowners policies has this location produced in the last 60 days?Additional Comments Required Documents:Copy of Agency Business Plan*Max. file size: 80 MB. Copy of Loss Run from a Standard Homeowners Market*Max. file size: 80 MB. Copy of Loss Run from a second Standard Homeowners Market*Max. file size: 80 MB. Copy of Agency's IRS Form W-9Max. file size: 80 MB. Optional Documents:Loss Runs from Specialty Lines carriers Drop files here or Select files Max. file size: 80 MB. Additional Comments:As the Agency Principal, I hereby declare the information provided to Tower Hill Insurance Group, LLC, in this document is true and correct.* I agree
