Gabor Insurance Services, Inc.

*FEIN:
*Year Agency Founded:
*Principal and percent of ownership (1):	%
Principal and percent of ownership (2):	%
Principal and percent of ownership (3):	%
*Commercial Lines Manager:
*Personal Lines Manager:
Full Name and License # of Agent to be listed and reported as Producing Agent on E&S Policies:
*Name:
*License #:
*Accounting Contact:
*Accounting Contact Extension:
*Accounting Contact Email:
Email Address where all monthly statements will be sent:
Policies are issued electronically. Do you prefer to receive by:
Email Address where all policies will be sent:
Contact name to receive CDs:

*Admitted Companies Licensed with (1):
Admitted Companies Licensed with (2):
Admitted Companies Licensed with (3):
Admitted Companies Licensed with (4):
Admitted Companies Licensed with (5):
*Surplus Lines Brokers you write with (1):
Surplus Lines Brokers you write with (2):
Surplus Lines Brokers you write with (3):
Surplus Lines Brokers you write with (4):
Surplus Lines Brokers you write with (5):
*Total Agency Volume:	$
*Total E&S Volume:	$
*Major class of Admitted Business written:
*Major class of E&S Business written:
Do you write Professional Liability?
If you write professional liability, what volume?	$
If you write professional liability, what major line?:

*Name of E&O Carrier:
*Limits:
*Expiration Date:
*Deductible:
*Policy #:
Has any member of your firm received any diciplinary action by a state insurance department or regulatory authority?
Has any principal of the agency ever declared bankruptcy?
Are all premiums kept in a segregated trust account?
Has this agency or any principal of this agency ever had a producer agreement with Gabor Insurance Services, Inc or American Professional Liability Underwriters?
If yes, Name of Agency:

Producer Questionnaire