Ramsgate Insurance, Inc. - Agency QuestionNaire:
Ramsgate Program Managers

Please complete the following online application  
Click the submit button at the bottom when finished
 
   
 
Mailing Address 1:    Suite#:     
City:     
State:    Zip code:     
     
Mailing Address 2:    Suite#:     
City:     
State:    Zip code:     
     
Phone Number:     
Fax Number:   
 
 
 
 
 
 
 
Business Status:   
Agency Ownership Names:
 
Name 1:    Title / Duties 1:
 
Name 2:    Title / Duties 2:
 
Name 3:    Title / Duties 3:
 
KEY PERSONNEL / CONTACTS:
Contact Name 1:    Duties 1:
 
Contact Name 2:    Duties 2:
 
Contact Name 3:    Duties 3:
 
Contact Name 4:    Duties 4:
 
Estimated Annual   
Premiums:   		 $  
Admitted:    %  
Non-Admitted:    %  
TOP 5 DIRECT APPOINTED COMPANIES: (EXCLUDE BROKERAGE)
 
 
Years Appointed1:    
     
 
Years Appointed2:    
     
 
Years Appointed3:    
     
 
Years Appointed4:    
     
 
Years Appointed5:    
TOP 3 WHOLESALE / MGUS:
Volume1:     
Volume2:     
Volume3:     
Additional required Information:
E & O Carrier:     
Limits:     
Expiration Date:     
     
Bank Reference:     
Personal Lines: %   Commerical Lines: %    
Workers Compensation: %     Other: %

I understand that the information provided herein is essential and material to the agency/broker relationship
and hereby certify the above answers are truthful and accurate, to the best of my knowledge.

If you have any questions, please call (800) 394-2767
Name:     
Title:     
     
 
     

Please also download, complete, sign and return the following:

Ramsgate Appointment Agreement

IRS W 9 Tax Form
     
                
     
This information is kept private and secure, and will not be sold.