Prospective Coverholders

Prospective U.S. Coverholder Questionnaire

Thank you for taking the time to complete this important survey. It should only take about 8 minutes to complete. And for 8 minutes of your time we will give you a forum to help shape our group!

(NO EXISTING BINDING AUTHORITIES THROUGH LONDON MARKETS)

NOTE: All information will be treated as confidential. No specific details regarding your program will be released to anyone without your prior authorization.

Question Title

* 1. General Agency Information

Agency Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Question Title

* 2. Does the Agency transact business under any other name?

Yes

Not sure