Agency Name Use the full legal name of the company. Dirección Ciudad Estado Agency State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Distrito de Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Nueva Hampshire Nueva Jersey Nuevo México Nueva York Carolina del Norte Dakota del Norte Ohio Oklahoma Oregon Pennsylvania Rhode Island Carolina del Sur Dakota del Sur Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Código Postal Teléfono Sitio Web (Opcional) Agency Principal Name Agency Principal Email Address Agency Principal Phone Number Key Contact Name (Opcional) Key Contact Email Address (Opcional) Key Contact Phone Number (Opcional) Agency Information Answer some questions about your agency’s business. Year Agency Established Number of Commercial Lines Producers Is your agency currently a member of an aggregator? Sí No What's the name of the aggregator? Agency Volume Share some information about your agency's book of business. What is your agency’s total written premium? $ What percent of your agency's premium is in Personal Lines? % What percent of your agency's premium is in Commercial Lines? % List your top three Commercial Lines carriers and total written premium for each. Please put N/A where appropriate. #1 Commercial Carrier #1 Carrier: Total Written Premium $ #2 Commercial Carrier #2 Carrier: Total Written Premium $ #3 Commercial Carrier #3 Carrier: Total Written Premium $ Choose your top five targeted industries (Choose at least 1) 5 max CLEAR ALL Agriculture Auto Services Business & Professional Services Construction Cultural Organization Entretenimiento Finance & Insurance Governmental Governmental & Public Entity Asistencia Médica Law Firms Biología Media & Advertising Metal Manufacturing Mining Other Manufacturing Plastics Manufacturing Printing & Publishing Servicios Profesionales Bienes Raíces Restaurants Al por menor Escuelas Tecnología Transportation & Utilities Wholesale Agency Demographic Information The Hartford's commitment to Diversity, Equity and Inclusion is one of our top priorities. Increasing our commitment starts with understanding more about our Agency demographic information. We invite you to provide us with your gender, race and ethnicity so that we understand more about your identity and drive towards inclusive outcomes. Agency principal(s)’s gender identity Femenino Masculino Non-binary Not Listed Prefer not to answer Agency principal(s)’s race CLEAR ALL American Indian or Alaska Native Black or African American Asian or Asian American Native Hawaiian or Pacific Islander Blanco Other race not listed Prefer not to answer Agency principal(s)’s ethnicity identity Hispanic, Latinx or Spanish origin Not Hispanic, Latinx or Spanish origin Prefer not to answer Signature and Certification Please sign the form certifying the information you provided is correct. Please share any additional information or questions in the comments. By my signature below, I certify that the information I just provided in this form is complete and accurate. If an appointment is offered to me and my agency, I understand that a background check may be conducted on me and all my staff members as part of the appointment process. Please indicate any comments or questions you may have. (Opcional) Signature Enviar