* 1. Employee(s) conducting visit

* 2. Agency Name

* 3. AIM Agent Number

* 4. Agency address

* 5. Agency Website address

* 6. Agency's written premium with BDI

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

* 8. Date of visit

Date/Time
/
/
:

* 9. Individuals visited and their email addresses

* 10. Agency Statistics

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

* 12. Issues discussed

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

* 14. Details/Notes of visit

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

  1 2 3 4 5
Visit

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