Strong Tower Specialty - Gethsemane Financial Group, Inc.

Legal Agency Name

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DBA (if applicable)

EIN

Physical Address

Is Physical Address Same as Mailing Address?

Yes
No

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Website

Phone

Fax

General Email

Principal #1:

Name

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Title

Ownership

Principal #2:

Name

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Title

Ownership

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Principal Agents NPN

Parent Company (if any)

Year Established

States Licensed To Operate

Agency License Number(s)

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Resident State

Non-Resident States

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E&O Carrier Name

E&O Policy Number

E&O Limits ($1M minimum Aggregate limit)

E&O Expiration Date

Primary Lines of Business Written (P&C, Personal, Commercial, Specialty)

Current Wholesale Relationships

Approximate Annual Premium Volume

Target Classes for STS Placement (E&S)

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Number of Employees

Sub-Producer Model?

Yes
No

Accounting Contact

Claims Contact

Does your agency accept fees?

Yes
No

Describe your agency’s compliance procedures

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Agency License(s)