Fields with an asterisk (*) are required.

Agency name

Entity type

FEIN

Main contact

Title

Agency phone

Agency website

Physical address

City

State

Zip code

County

Mailing address (if different from physical address)

City

State

Zip code

County

Year established

Number of producer(s)

Number of CSR(s)

Is agency owned by, affiliated with, or controlled by any other business interest?

If yes, please explain:

Does your firm operate as a Wholesaler, Retailer, MGA, or combination thereof? (please indicate percentage of total business)

Retailer %

Wholesaler %

MGA %

Are you a member of an association or organization? (check all that apply) WSIA PLUS

Other

Current (est.) $

Prior $

Companies represented and premium volume (top 3)

In which product lines or industries does your agency specialize (i.e. Commercial Package, Workers Compensation, Professional, etc.)?

Provide annual premium volume by major line of business (top 5)

List any companies retired in the past 5 years and reason(s) for termination

How would you plan to utilize a Markel contract?

Agency prospect survey

If you have any questions, please contact Agency Services at +1.888.500.3344 or agencyappointment@markel.com.