Agency Name
First Name
Last Name
Phone Number
Email Address
Website
Address
City
State Zip/Postal Code
What is the split between personal and commercial lines:
How long has your agency been in business:
Why are you interested in an appointment with Michigan Insurance Company:
Do you have Branch offices? Yes No Total Annual P & C Premium Volume:
Loss ratio for the last 3 years:
How did you hear about Michigan Insurance Company:
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