Broker Profile

Company Name:			Principal/Owner:
E-Mail Address:			Phone Number:
Year Business Established:			Number of Employees:
How is your Brokerage Licensed (I.E. Agent, Broker, Excess & Surplus Lines Broker)?

Premium Volume Distribution	Current Year	Prior Year
Commercial Auto
Public Auto (Livery)
Workers Compensation

List Major Companies/Wholesalers You Represent in Order of Premium Volume:
Name	Annual Premium	Line of Business	Commission

Has Your Account With Any Company Been Suspended or Terminated?		Yes	No Test
Company : Enter Company Name	Reason : Enter Company Reason

Has Your Brokerage or any of its Owners, Principals, Partners or Employees Had a Company or Individual License Suspended or Revoked?		Yes	No
If Yes, Please Give Details : Enter Reason

Has Your Brokerage or any of its Owners, Principals, Partners or Employees Had any Disciplinary Action by a State Insurance Department or Other Regulatory Authority?		Yes	No
If Yes, Please Give Details : Enter Reason

Has Any Principal, Owner or Partner Been Convicted of a Crime?		Yes	No
If,Yes Give Details : Enter Reason

Is There Any Pending, Threatened, or in the Last Five Years, any Litigation or Judgments Exceeding $10,000 Against the Brokerage or Any of the Principals?		Yes	No
If,Yes Give Details : Enter Reason

Has Your Brokerage or any Principal, Owner or Partner Ever Filed for Bankruptcy or Re-Organization Under Bankruptcy Law?		Yes	No
If,Yes Give Details : Enter Reason

Have you or Your Brokerage Been Party to Any Errors and Omissions suit in the Last Five Years:		Yes	No
If,Yes Give Details : Enter Reason

I hereby affirm, under the penalty of perjury, that the information provided in the application is true and accurate. Maya Assurance Company Conducts Background Checks on all Brokerages, their Owners, Principals and Partners. Your Signature Below Authorizes Maya Assurance Company to Conduct Such an Investigation.

Signature		Name (print)
Title		Date	(MM/dd/yyy)