UGA New Member Application Step 1 of 10 10% Basic Agency InformationAgency Name:Agency Owner: First Last Email Address: Enter Email Confirm Email Phone Number:Website: Agency Address: Street Address City ZIP Code Agency OverviewYear Agency Established:Number of years licensed to sell Property & Casualty:select0-1 year(s)1-5 year(s)5-10 years10+ yearsDo additional Agency Principals exist? Yes No If yes, please list names and roles.Click "+" to add more than one.First Name:Last Name:Role: Add RemoveTotal Number of Employees (including producers):Number of Producers (licensed sales staff): Business ProfileTotal Premium Volume:Business MixPersonal Lines %:Commercial Lines %:Life / Benefits %: Add RemoveTop CarriersClick "+" to add more than one.Carrier Name:Premium Volume: Add Remove Operations & TechnologyCurrent Technology Platforms:Do you currently have a formal sales process in place? Yes No Do you have a dedicated marketing strategy or budget? Yes No If yes, briefly describe.What are your primary lead sources?select all that apply. Referrals Digital Purchased Leads Walk-in Other Compliance & Risk ManagementDoes your agency carry Errors & Omissions Insurance?(Required) Yes No Does your agency carry Cyber Liability Insurance?(Required) Yes No Have you been terminated by any carriers in the last 5 years?(Required) Yes No If yes, please explain.(Required) Experience & CapabilitiesDo you consider yourself and/or your staff proficient in Personal Lines? Yes No Do you consider yourself and/or your staff proficient in Commercial Lines? Yes No Do you understand and agree to routinely review and re-underwrite business placed with our carriers? Yes No What areas of your business are you most looking to improve?select all that apply. Sales Carrier access Technology Training Operations Other Background & Regulatory QuestionsHave you or any agency partners/producers had a license:(Required)Denied, suspended, revoked, or non-renewed? Yes No If yes, explain.(Required)Have you or any agency partners/producers been:(Required)Disciplined, fined, or censured by a regulatory body or court? Yes No If yes, explain.(Required)Have you or any agency partners filed for bankruptcy in the past 5 years?(Required) Yes No If yes, explain.(Required)Have you or any agency partners/employees been convicted of criminal activity?(Required) Yes No If yes, explain.(Required) Business QualificationsAgency has been in business for more than 2 years? Yes No Applicant has more than 2 years of insurance experience? Yes No Is there a director/officer with 2+ years of management experience? Yes No Premium & Growth GoalsAnnual Agency Revenue (Insurance & Financial Services):select$0 - $100,000$100,000 - $300,000$300,000 - $500,000$500,000+Premium Goals (enter "0" if startup):Current Premium:Year 1 Goal:Year 2 Goal:Year 3 Goal: Add RemoveWhat are your growth goals over the next 3–5 years?What is motivating you to explore joining a network at this time? Final Alignment & SubmissionWhat are you hoping to gain from a partnership with our network?What challenges are you currently facing in your agency?Acknowledgement:(Required) "I certify that the information provided is accurate and complete to the best of my knowledge."
