Company Name
Yes, I'm Interested In The
Strategic Partners Program!
Street Address:
City:
State:
Zip:
Your Name:
Your Title:
Agency Name:
Your Phone:
Your Fax:
Your E-Mail:
Fields Highlighted In Red Must Be Completed
What Licenses Are Currently Held In The Agency:
(Check All That Apply)
Is Your Agency Currently Active In Voluntary Benefit (Worksite Marketing) Plans:
How Many Commercial Accounts Does Your Agency Currently Service:
What Is The Average Size Of Your Agency's Commercial Accounts:  (By Number of Employees)
Are You Actively Involved In Selling Voluntary Benefits (Worksite):
Please provide a brief description of your agency specifically detailing:
1.)The market(s) you serve
2.)Areas of expertise
3.)Any involvement in program business
How Many Licensed Producers Are In Your Agency:
P & C
Life
Health
Other
Yes
No
Yes
No