Employee(s) conducting visit

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* 1. Employee(s) conducting visit

Date of visit

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* 2. Date of visit

Date/Time
Agency Name

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* 3. Agency Name

AIM Agent Number

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* 4. AIM Agent Number

Agency address

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* 5. Agency address

Agency Website address

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* 6. Agency Website address

Agency's written premium with BDI

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* 7. Agency's written premium with BDI

Is agent captive? If so, choose which company

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* 8. Is agent captive? If so, choose which company

Individuals visited and their email addresses

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* 9. Individuals visited and their email addresses

Agency Statistics

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* 10. Agency Statistics

Other E & S Wholesalers used and why?

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* 11. Other E & S Wholesalers used and why?

Issues discussed

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* 12. Issues discussed

Is there someone specifically from BDI you would like to visit your office?

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* 13. Is there someone specifically from BDI you would like to visit your office?

Details/Notes of visit

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* 14. Details/Notes of visit

Success of visit (with 1 being the worst and 5 being best)

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* 15. Success of visit (with 1 being the worst and 5 being best)

  1 2 3 4 5
Visit

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