STANDARD.doc
STANDARD AGENT/BROKER INFORMATION SHEET
Please type or print your answers and return it with your Agent Agreement and License. If you have any questions, please contact your Broker Relations Liason, Jennifer Murray (413) 787-4000 x3380.
Name of Agency: ________________________________________________________________
Principal
Address:__________________________________________________
Mailing
Address_____________________________________________________
Email
Address:
_____________________________________________________
Telephone
#___________________________
Facsimile #
_______________________________
Type of Firm:
(check one)
Corporation
__________ Partnership ___________ Individual _____________
Taxpayer I.D.
Number:
_____________________________
Year Business
Established: _____________
During the past 5
(years) has the firm changed names or acquired/merged with another firm?
YES: _____ NO: ____ If Yes, explain:
__________________________________________________________________________________________________________________________________
Is the firm
currently engaged in, owned or controlled by any other business interest?
YES:
______________ NO: ______________ If Yes, explain: ________________________________________________________________________________________________________________________________________________
ealth New England
Broker Manual