Everest National Insurance

Program Quick Data Sheet

* required fields are in red

Agency Name :
Agency Street Address:
Agency State: Agency Zip Code:
Type of Agency:
Agency Contact's Name :
Agency Contact's Phone Number :
Agency Contact's E-Mail Address:
Agency's Web Page Address:
Name of Agency's Agency Management System & Version #:

Name of Program:
Brief Description of the Program:
Is the program Affiliated with a sponsoring organization: Yes No
If yes, name of organization:
Organization's web page address (if any):

Approximate Annual Premium:
Proposed Implementation Date:
Does the agency/program desire to be a risk sharing partner: Yes No
Type of Program:
Program Structure:
How are the following to be handled:
Marketing	Underwriting
Claims	Loss Control
Lines of Business: Homeowners Personal Automobile Non-Standard Personal Automobile Commercial Package Commercial General Liability Commercial Fire Commercial Inland Marine	Workers Compensation Professional Liability Earthquake Directors & Officers Environmental Other

States Where Written:

Please address specific problems, needs, role of sponsoring organization (if any), loss experience, current carrier, etc