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Name
 
Company Name
 
Address
 
City/State/Zip
 
Office phone
 
Cell phone
 
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Fax number
 
Best time to call
 
E-mail address
 
Web address

  Please answer the following so we may better respond to your request for information:
   
1.
Current carrier:
F & G Chesapeake Americo Chase Shenandoah U/Omaha
2.
Amount of paid-for premium:
3.
Submit to placement ratio percentage
4.
Your 13-month persistency percentage
5.
States operating in
6.
Number of Agents
Number of General Agents
Number of MGAs
Number of IMOs

In the space below, explain why you want to do business with us:



 

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Kruger Brent Limited • P.O. Box 900 • Basye, VA 22810-0900
Tel (540) 856-3223
Fax (206) 350-4550

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