American Modern

Are you interested in an appointment with American Modern?

We appreciate your interest in American Modern. To get started, please complete the following questionnaire so we can match you with the appropriate member of our team for further discussions.

Your Information

 
Your First Name*
 
 
Your Last Name*
 
 
 
Your Office Phone*
 
 
Your Cell Phone*
 
 
 
Your Email*
 
 
 
Your Position @ Agency
 
 
 

Agency Information

 
Agency Name (As Licensed)*
 
 
Agency Address*
 
 
Agency City*
 
 
Agency County*
 
 
Agency State*
 
 
Agency Zip*
 
 
Agency Website*
 
 
Agency Type (Select Most Appropriate)*
 
 
 
Name of Aggregator Group if Selected
 
 
If Other Describe
 
 
Agency Business Model*
 
 
 
Number of Employees(Agents & CSR's)*
 
 
Number of States Agency is Licensed in
 
 
 
Primary Writing States (separate with commas)
 
 
Length of Time in Business (Year Established)
 
 
 
Total Premium Volume
 
 
Personal Lines Percentage
 
 
Commercial Lines Percentage
 
 
Do you carry Errors and Omissions Coverage?
 
 
 
 
Policy Limit
 
 
 

Carriers Represented:

In the first column list the top 3 primary personal lines carriers.  In the second column enter the premium volume of each of the carriers on the left.

 
Primary Personal Line 1
 
 
Line 1 Premium Volume
 
 
Primary Personal Line 2
 
 
Line 2 Premium Volume
 
 
Primary Personal Line 3
 
 
Line 3 Premium Volume
 
 

Carriers Represented:

In the first column list the top 3  specialty personal lines carriers.  In the second column enter the premium volume of each of the carriers on the left.

 
Specialty Personal Line 1
 
 
Line 1 Premium Volume
 
 
Specialty Personal Line 2
 
 
Line 2 Premium Volume
 
 
Specialty Personal Line 3
 
 
Line 3 Premium Volume
 
 

General Information

 
Have you worked with/Represented American Modern Previously?
 
 
 
 
If yes, through whom?
 
 

How do you see American Modern being used in your agency? Check all that apply:

 
Rarely, Specialty lines business is not common in the agency
 
 
Occasionally (weekly), we do not write much specialty personal lines business
 
 
Regularly (daily), we write a good volume of specialty lines business
 
 
Heavily, our agency focus is specialty lines
 
 
We wish to transfer a book of business
 
 
Other
 
 
Other (Please Specify)
 
 

The American Modern products I am most interested in are? Check all that apply:

 
Mobile/Manufactured Home
 
 
Specialty Residential Dwelling (vacant, dwelling basic & special, homeowners)
 
 
Motorsports
 
 
Collectible Vehicle
 
 
Landlord Schedules
 
 
Pet Health
 
 
Boat/Yacht
 
 
Other
 
 
Other (Please Specify)
 
 
Any additional comments you wish to provide?