http://www.choosetaginsurance.com/becomeanagent/

Become an Agent

TAG Information Questionnaire

Begin your new career today as an independent insurance agent.

First Name *

Last Name *

Agency Name

Email Address

Phone Number *

Fax

Address

City

State *

Zip *

Tax ID

Date of Birth

Are there any producers under investigation or subject to administrative review now or in the previous 3 years?

Yes

Have any producer or company contracts been cancelled in the previous 3 years?

Yes

Have any producers in your office ever been convicted of a felony?

Yes

Has your business, or any principles or owners ever been subjected to a fine or other disciplinary action from the DOI or other regulatory agencies?

Yes

How many years have you been in business?

Previous Employer

How long with the company?

Written Premium

Loss Ratio

New Business Written in the Last 12 Months

Percentage Personal Lines

Percentage Commercial Lines

Background of Agency or Individual (Experience, Training, etc.)

Additional Information You Would Like Us to Know

Anticipated Start Date

We will never sell your email address to any 3rd party or send you nasty spam. Promise.

For more information, before completing this form you can contact Cory Louthan at (303) 565-1854 or clouthan@tagins.net