AssuranceAmerica - Payments

Let's start with the basics

What is your full legal name?

Please include DBA

What is your company website?

We can help integrate links to our products on your website to make it easier for you and your customers.

How can customers get in touch with you?

What is Your Business Address?

We'll need your street address, city, state, and zip code.

Your Business Telephone Number:

Your Business Fax:

Main Email Address:

Tell us a little about your workplace

Number of CSR's:

Number of Licensed Agents:

Owners and Management:

Please provide us with the name and title of your Owner, General Partners or Corporate Officers.

Have there been any ownership changes in the last 5 years?

Please provide details of these changes in ownership.

What Year was Your Agency Established?

Number of Office Employees:

What kind of business do you do?

Number of Auto Companies Represented:

Total Premium of Agency $:

Personal $:

Commercial $:

Personal Lines Mix:

Percentage of Auto vs Other (Home Owners and Specialty Lines)

Number of Locations:

Top 3 Companies Represented

Please provide a general overview of the top three companies represented (other than life, WC & Health), no abbreviations.

Total Premium of Non-Standard Auto:

What companies have withdrawn in the last 3 years and why?

Error & Omissions Carrier:

Please provide the name of the Error and Omissions Carrier, if applicable.

How did you hear about us?

* If you selected Other, please provide the details about how you heard about us below. Otherwise, type N/A: