Exit this survey Agency Visit Report Question Title * 1. Employee(s) conducting visit Question Title * 2. Date of visit Date/Time Date Time AM/PM - AM PM Question Title * 3. Agency Name Question Title * 4. AIM Agent Number Question Title * 5. Agency address Question Title * 6. Agency Website address Question Title * 7. Agency's written premium with BDI Two years ago Last year YTD Question Title * 8. Is agent captive? If so, choose which company Nationwide Erie Allstate Other (please specify) Question Title * 9. Individuals visited and their email addresses Person #1 Email #1 Person #2 Email #2 Person #3 Email #3 Person #4 Email #4 Question Title * 10. Agency Statistics % of Personal Lines Business % of Commercial Business % of E & S Business Question Title * 11. Other E & S Wholesalers used and why? Question Title * 12. Is there someone specifically from BDI you would like to visit your office? Question Title * 13. Details/Notes of visit Question Title * 14. Success of visit (with 1 being the worst and 5 being best) 1 2 3 4 5 Visit Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Done