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Berkshire Hathaway Homestate Companies

Agency Questionnaire

Property and Casualty Application for Appointment

Legal Name of Agency:

("The Agency")

Does this Agency use a name other than the legal name? (i.e. DBA, T/A) Yes No

If yes, please provide:

Phone #:

Fax #:

FEIN/Tax ID:

Verify FEIN:

Agency Website:

Physical Address (If additional offices, to be listed later in application)

Address Line 1:

Address Line 2:

City, State, Zip:

Statements and commissions sent to this address.

INCLUSION ON BHHC WEBSITE

On behalf of "Agency", I authorize Berkshire Hathaway Homestate Companies to list "Agency" on its "Locate an Agent" link on its website.

Include this location on BHHC Website? Yes No

Is the mailing address different than the Physical Address? Yes No

Mailing Address:

Address Line 1:

Address Line 2:

City, State, Zip:

Statements and commissions sent to this address.

Are statements and commissions to be sent to an address other than Physical or Mailing? Yes No

Accounting Address

Address Line 1:

Address Line 2:

City, State, Zip:

Agency Type: Retailer Wholesaler

Business Type: Sole Proprietorship Partnership Corporation LLC

Contact Information

Appt. Contact Name:

Appt. Contact Phone #: Ext.:

Appt. Contact Fax #:

Appt. Contact Email:

Website Contact Name: ? Same as Appt. Contact

Website Contact Email:

Claims Contact Name: ? Same as Appt. Contact

Claims Contact Email:

Contract Contact Name: ? Same as Appt. Contact

Contract Contact Email:

Accounting Contact Name: ? Same as Appt. Contact

Accounting Contact Email:

Is there a separate email address for electronic policies? Yes No

Email (Policies):

Continue

Who We Are

Berkshire Hathaway Homestate Insurance Company
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