ACORD 812 (2006/02) 1 of 5
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 812 (2006/02) |
Agency Questionnaire |
This form is used to collect information that is commonly required of agencies to provide to their carriers. |
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IDENTIFICATION SECTION |
Date (MM/DD/YYYY) |
Month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
The name and address of the main agency location. |
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IDENTIFICATION SECTION |
Primary Contact |
The primary contact that should be used by the carrier to contact the agency. |
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IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Producer's telephone number. |
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IDENTIFICATION SECTION |
Fax No. (A/C, No, Ext) |
Producer's fax number. |
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IDENTIFICATION SECTION |
E-Mail Address |
Producer's e-mail address. |
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IDENTIFICATION SECTION |
Website Address |
Producer's website address. |
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IDENTIFICATION SECTION |
Fiscal Year End |
The date of the producer's fiscal year end. |
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IDENTIFICATION SECTION |
Nat'l Producer Number |
The identifier assigned to an individual producer/agent/broker/agency by the NAIC. |
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IDENTIFICATION SECTION |
Contract Number |
The producer's contract number with the carrier. This is also known as the Agency Code. |
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IDENTIFICATION SECTION |
FEIN |
The producer's Federal Employer Identification Number. |
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IDENTIFICATION SECTION |
City Population |
The population of the city of the main agency location. |
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E & O |
Carrier |
The name of the producer's Errors and Omissions carrier. |
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E & O |
Expiration Date |
The expiration date of the producer's E&O policy. |
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E & O |
Limits - Ea Claim |
The per claim limit on the producer's E&O policy. |
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E & O |
Limits - Ea Occ |
The per occurrence limit on the producer's E&O policy. |
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E & O |
Limits - Aggregate |
The aggregate limit on the producer's E&O policy. |
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AGENCY PROFILE |
Name |
The agency employee's name. Repeat the employee's information for each state in which they are licensed. |
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AGENCY PROFILE |
Title |
The agency employee's title. |
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AGENCY PROFILE |
E-Mail Address |
The agency employee's e-mail address. |
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AGENCY PROFILE |
Hire Date |
The hire date of the agency employee. |
ACORD 812 (2006/02) 2 of 5
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Section Name |
Field Name |
Field and/or Section Description |
|
AGENCY PROFILE |
Professional Designations |
The description of designations the agency employee has received. |
|
AGENCY PROFILE |
P & C Agency License Number |
The employee's P&C License Number. |
|
AGENCY PROFILE |
P & C Broker License Number |
The employee's P&C Broker Number. |
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AGENCY PROFILE |
Life & Health License Number |
The employee's Life & Health License Number. |
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AGENCY PROFILE |
State |
The state the employee's license is applicable to. |
|
AGENCY/BRANCH OFFICES |
Agency/Branch Name and Address |
The name and address of additional agencies and branches associated with the main agency. |
|
AGENCY/BRANCH OFFICES |
Primary Contact |
The primary contact that should be used by the carrier to contact the agency/branch. |
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AGENCY/BRANCH OFFICES |
Phone (A/C, No, Ext) |
Producer's telephone number. |
|
AGENCY/BRANCH OFFICES |
Fax No. (A/C, No, Ext) |
Producer's fax number. |
|
AGENCY/BRANCH OFFICES |
E-Mail Address |
Producer's e-mail address. |
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AGENCY/BRANCH OFFICES |
Website Address |
Producer's website address. |
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AGENCY/BRANCH OFFICES |
Fiscal Year End |
The date of the producer's fiscal year end. |
|
AGENCY/BRANCH OFFICES |
Nat'l Producer Number |
The identifier assigned to an individual producer/agent/broker/agency by the NAIC. |
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AGENCY/BRANCH OFFICES |
Agency License Number |
The producer's license number. |
|
AGENCY/BRANCH OFFICES |
FEIN |
The producer's Federal Employer Identification Number |
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AGENCY/BRANCH OFFICES |
City Population |
The population of the city of the main agency location. |
|
AGENCY/BRANCH OFFICES |
Carrier |
The name of the producer's Errors and Omissions carrier. |
|
AGENCY/BRANCH OFFICES |
Expiration Date |
The expiration date of the producer's E&O policy. |
|
AGENCY/BRANCH OFFICES |
Limits - Ea Claim |
The per claim limit on the producer's E&O policy. |
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AGENCY/BRANCH OFFICES |
Limits - Ea Occ |
The per occurrence limit on the producer's E&O policy. |
ACORD 812 (2006/02) 3 of 5
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Section Name |
Field Name |
Field and/or Section Description |
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AGENCY/BRANCH OFFICES |
Limits - Aggregate |
The aggregate limit on the producer's E&O policy. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Company |
List all carriers that the agency writes business with. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Commercial Lines Volume |
Enter the premium volume of the agency (in dollars) attributed to commercial lines policies with the carrier. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Personal Lines Volume |
Enter the premium volume of the agency (in dollars) attributed to personal lines policies with the carrier. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Life & Health Volume |
Enter the premium volume of the agency (in dollars) attributed to Life & Health lines policies with the carrier. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Loss Ratio |
Enter the loss ratio with the carrier for the line of business. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Interface - Download |
Check this box if the carrier offers download for the line of business. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Interface - Upload |
Check this box if the carrier offers upload for the line of business. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Interface - Real-Time |
Check this box if the carrier offers real-time interface for the line of business. |
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AGENCY PREMIUM / MIX OF BUSINESS |
Interface - Website |
Check this box if the carrier provides a website to process this line of business. |
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TECHNOLOGY INFORMATION |
Vendor Name |
The name of your agency automation system vendor (e.g. Applied Systems, DORIS,etc.) |
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TECHNOLOGY INFORMATION |
System Name |
The name of your agency automation system (e.g. TAM, FILESERVEROnline, etc.) |
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TECHNOLOGY INFORMATION |
Model |
Enter the type of system model your agency is using (e.g. LAN, Local, ASP). |
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TECHNOLOGY INFORMATION |
Version |
Enter the version of agency automation software that your agency is currently running. |
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TECHNOLOGY INFORMATION |
# Workstations |
Enter the number of licensed workstations running the agency automation system software. |
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TECHNOLOGY INFORMATION |
Minimum System Speed |
The system speed in megahertz. |
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TECHNOLOGY INFORMATION |
Server Operating System |
Enter the operating system that is running on your server. |
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TECHNOLOGY INFORMATION |
Browser |
Enter the name of the internet browser used in your agency (e.g. Internet Explorer) |
ACORD 812 (2006/02) 4 of 5
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Section Name |
Field Name |
Field and/or Section Description |
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TECHNOLOGY |
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INFORMATION |
Browser Version |
Enter the version of the internet browser used in your agency. |
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TECHNOLOGY |
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INFORMATION |
User Group Name |
Enter the name of the user group from the Agency Automation System. |
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TECHNOLOGY |
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Check "Yes" if you are an active member of the user group. Click "No" if you do not |
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INFORMATION |
Active Member |
participate in the user group. |
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TECHNOLOGY |
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Check "Yes" if you are currently paying support fees for your agency automation system. |
|
INFORMATION |
Do you pay technical support? |
Click "No" if you are not paying support fees for your agency automation system. |
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TECHNOLOGY |
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INFORMATION |
Describe other support |
Describe any other support that your agency receives. |
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TECHNOLOGY |
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Enter the date you last installed an update to your existing version of agency automation |
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INFORMATION |
Date last patch installed |
system software. |
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TECHNOLOGY |
Date last version upgrade was |
Enter the date you last upgraded to a complete new version of agency automation system |
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INFORMATION |
installed. |
software. |
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Agency staff that participate |
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regularly in day-to-day use of |
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TECHNOLOGY |
agency automation system for |
Check the boxes next to all agency personnel that work in the agency automation system |
|
INFORMATION |
sales and/or service |
on a day-to-day basis. |
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TECHNOLOGY |
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INFORMATION |
Type of connection to the internet. |
Check the box next to the type of internet connection used in the agency. |
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TECHNOLOGY |
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INFORMATION |
Rating Vendor Name |
If your agency uses a comparative rater, enter the rating system vendor name. |
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TECHNOLOGY |
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INFORMATION |
Rating System Name |
Enter the system name of the rating software used in the agency. |
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TECHNOLOGY |
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INFORMATION |
Key Agency IT Contact(s) |
Enter the name(s) of the key agency information technology contacts. |
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TECHNOLOGY |
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INFORMATION |
E-Mail Address |
Enter the e-mail address(es) of key agency information technology contacts. |
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GENERAL INFORMATION |
Does every employee in your agency have a work station with access to: a) Internet, b) e-mail, c) agency automation system. |
Check "Yes" next to each question that applies to all workstations within your agency. Check "No" next to each question that does not apply to all work stations within your agency. |
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Section Name |
Field Name |
Field and/or Section Description |
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Does your agency input policy and |
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transactional detail for only |
Check "Yes" if you do not enter full detail in your agency automation system for all lines of |
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GENERAL INFORMATION |
specific types of business? |
business. |
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Does your agency plan on |
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changing your agency automation |
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GENERAL INFORMATION |
system vendor within the next year? |
Check "Yes" if you are planning on shopping for a new agency automation system within the next year. |
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REMARKS |
Remarks |
Enter any additional comments you would like the carrier to receive. |
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Enter the agency number used to identify the agency in the agency automation system. |
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AGENCY LICENSE |
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Repeat the agency/branch information for each state in which the agency/branch is |
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NUMBERS |
Agency # |
licensed. |
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AGENCY LICENSE |
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NUMBERS |
Branch # |
Enter the branch number used to identify the branch in the agency automation system. |
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AGENCY LICENSE |
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NUMBERS |
Agency/Branch Name |
Enter the name of the agency/branch. |
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AGENCY LICENSE |
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NUMBERS |
License Number |
Enter the agency/branch license number. |
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AGENCY LICENSE |
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NUMBERS |
State |
Enter the state that issued the license number. |