Request Appointment | Upland Capital Group

Corporate Address:

City:

State:

Zip:

Number of Locations:

Years in Business:

Has the name of the company changed?

YesNo

Has the company been sold / acquired?

YesNo

Has the company merged with another?

YesNo

Are you an MGA?

YesNo

Do you operate exclusively as a Wholesale Broker?

YesNo

Do you operate as a Retail Broker?

YesNo

Is your company a current member of:

WSIA

YesNo

AAMGA

YesNo

Has the company had any E&O claims in the last 5 years?

YesNo

Has your E&O insurance ever been cancelled or increased due to claims activity / poor loss results?

YesNo

Has anyone in your company been under investigation or convicted by any regulatory body with respects to unfair business practices, deceptive trade practices, insurance fraud or other violations?

YesNo

Have any carrier contracts been terminated / non-renewed by you or against your company in the last 36 months?

YesNo

Do you have proof of E&O Insurance Policy showing limits of at least $2,000,000?

YesNo

Do you have proof of Fidelity Insurance Policy?

YesNo

Do you have a Brokerage Agreement?

YesNo

What is the company’s total Annual Written Premium:

What states has your company obtained P&C and Surplus Licenses in:

Name:

Phone:

Email:

Mgmt. / Broker / AP:

Name:

Title:

Phone: