Agency Name

DBA

Contact Email

Address

City, State & Zip Code

Mailing Address

Mailing City, State & Zip Code

Federal Tax ID

Policy Distribution Email

If Other, please specify

KEY CONTACTS AND RESPONSIBILITIES

Name 1

Name 1 Position/Title/Responsibilities

Name 2

Name 2 Position/Title/Responsibilities

Name 3

Name 3 Position/Title/Responsibilities

TOP FIVE COMPANIES REPRESENTED OR GENERAL AGENCY RELATIONSHIPS

Company 1: Name or General Agent

Company 1: Year Appointed

Company 1: Commercial Lines Annual Written Premium

Company 1: Average Three-Year Loss Ratio

Company 2: Name or General Agent

Company 2: Year Appointed

Company 2: Commercial Lines Annual Written Premium

Company 2: Average Three-Year Loss Ratio

Company 3: Name or General Agent

Company 3: Year Appointed

Company 3: Commercial Lines Annual Written Premium

Company 3: Average Three-Year Loss Ratio

Company 4: Name or General Agent

Company 4: Year Appointed

Company 4: Commercial Lines Annual Written Premium

Company 4: Average Three-Year Loss Ratio

Company 5: Name or General Agent

Company 5: Year Appointed

Company 5: Commercial Lines Annual Written Premium

Company 5: Average Three-Year Loss Ratio

Premium Trust Account Bank Name

Premium Trust Account Bank Address

Accounting Email

If you heard about Granada Indemnity from a Marketing Rep or Other, please specify

IMPORTANT

Upon form submission, please send via email producer@granadainsurance.com or fax (516) 825-1947: - Errors & Omissions Declarations Page ($1,000,000 minimum limits required; $10,000 maximum deductible) - Broker (BR) License for each state in which you plan to write business - NY, NJ, PA & CT

Broker Application