Name *

What licenses do you hold? *

Address *

Contact phone & email *

What percentage of your book is commercial? *

What percentage of your book is written through direct contracts with carriers?

Please list the carriers, MGAs and program managers you have contracts with.

What state (s) are your policy holders in?

If your goal is to stay in the business, do you need to keep your present location and/or employees?

If you are looking to retire, do you want your employees to stay with the business?

What are your monetary goals for this merger or partnerthsip?

Reduce overhead Other Retire Remain with capital infusion