Prospective Agents

Agency Profile:

Dear Prospective Representative,

Thank you for showing an interest in Sterling Insurance Company. In order to be considered for an agency appointment, we will require that you submit an "Agency Profile". This can be accomplished in one of two ways:

(1) Online "Agency Profile" form - complete the profile and click the "Submit" button

(2) Print the "Agency Profile" form and mail or fax the completed profile to:

Sterling Insurance Company
PO Box 9
Cobleskill, NY 12043-0009

Fax: (518) 234-3167

Please note that submission of an Agency Profile does not guarantee that your agency will be appointed. The information we receive will be reviewed, and a company representative will contact your agency to discuss the possibility of a mutually beneficial relationship.

Please keep in mind that Sterling Insurance Company ONLY appoints licensed agents in the state of NEW YORK, USA.

Agency Profile Submission Form

Information:

Agency Name:
Street Address:
City:
State:	Sterling Insurance Company ONLY appoints licensed agents in the state of NEW YORK, USA.
Zip:
Phone:
Fax:
E-Mail:
Website (URL):
Date Agency Established:
Check One:	Corporation
	Partnership
	Sole Proprietor
Counties/Communities of Operation:
Mailing Instructions:	New - Agent
	Renewal - Agent
	New - Insured
	Renewal - Insured
Inflation Guard:	Yes		%
	No

Principals or Corporate Officers:
Name:		Title:





Premium Volume Breakdown (must equal 100%)
Personal Lines:		Commercial Lines:
% Home/Property		% Small Commercial
% Personal Auto		(under $10,000)
% Personal Umbrella		% Large Commercial
% Life/Health		(over $10,000)
% Financial Services		% Workers' Comp.
% Other		% Commercial Auto
		% Other
Companies Represented:
Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Company Represented:
Annual Written Premium Volume: $
3 Year Avg. Loss Ratio: %
Years Represented:

Total Agency Written Premium: $
Branch Offices:
Name:
(if different than main office)
Address:
Manager:
Phone:
Fax:

Name:
(if different than main office)
Address:
Manager:
Phone:
Fax:
Names of Cluster Affiliations and Subsidiary Operations:
1.
2.
3.
Other Corporate or Business Activities ( Real Estate, Tax Prep, etc.):

Agent / Broker Representatives:
Name:
Address:
License Number:

Name:
Address:
License Number:

Name:
Address:
License Number:

Name:
Address:
License Number:

Name:
Address:
License Number:

Name:
Address:
License Number:

( Note: Please attach copy of agency's PC license.)
Errors and Omissions:
Insurance Carrier:
Policy Number:
Limits:
Retention:
Policy Period:
Automation:
Agency Mgmt. System:
Model:
Version:
No. of carriers you are "downloading" with
No. of carriers you are "uploading" with
Specific Reasons for Wanting to Represent Sterling:
Message:

A consumer report may be requested by Sterling Insurance Company. The applicant, upon written request, will be informed whether or not a consumer report was requested. If such was requested the applicant will be informed of the name and address of the consumer reporting agency that furnished the report. The undersigned hereby applies to be a Sterling Insurance Company representative and affirms that the above statements and representations made herein are true to the best of his/her knowledge.

Agent's Signature:
Date: