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Agency Information

First Name
Last Name
Email
Company
City
State/Province
Salutation
Mobile
Title
Website
Fax
Phone
Address
Zip
Country
Lead Source
Description
Year Established:
License Number:
Licensed States:
Tax ID or SSN:
Total Number of Producers:
Total Agency Staff:
Principal's Name:
Principal's Title:

Mix of Business

Construction %:
Mercantile %:
Hospitality %:
Health Care %:
Automotive %:
Food/Agricultural %:
Manufacturing (all types) %:
Professional %:
Other %:

Workers' Compensation Experience Summary

Carriers:
Total Yearly Workers' Comp Volume:
WC States:
Submissions to Atlas a Month Expected?:

Contact Info

Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:

Other Info

A/S/P ever declared bankruptcy?:
A/S/P ever been convicted of a felony:
A/S/P ever been refused a license:
A/S/P ever been investigated by DOI:
Agency acts as whslr/appts subprod srcs.:
Amount of E&O Coverage:
E&O Claims in the past 5 years:
E&O discipline/investigated by DOI:
Legal Declaration:
License Expiration Date:
E&O Expiration Date:

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CONTACT

Toll-Free: (877) 66-ATLAS (28527)
Telephone: (619) 768-6580
Email: info@atlas.us.com