State Group Application Application Date: 7/4/2008
General Information
Group Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Group Information
Year Established:
# of Agencies in the group:
Name/Title of Group Contact:
Contact's Phone:
Contact's Email:

Agency Locations:
Geographic Area Covered:
Approximate population of geographic area covered:

Indicate membership in or franchise held in any other issuance groups:

Please provide premium estimation of the group's business:
Commercial Life/Health
Person Lines other

Additional Comments

Please forward any brochures or other history of the group with this application

If you have any questions or need additional information,
please feel free to contact Paul Ross at 630-285-4186.