DHIA - Daniels-Head Insurance Agency Inc.
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Broker Questionnaire
Broker Questionnaire
Please fill out the form in order to be appointed to submit business with Daniels-Head
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AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Company Type
Corporation
Partnership
Individual
Are you a member of any agency association?
Yes
No
Are you a wholesaler?
Yes
No
Principals & Personnel, Please breakdown the number of staff (number input for each):
Do you maintain Errors and Omissions Coverage?
Yes
No
Has any member of your firm received any disciplinary action by a state insurance department or other regulatory authority?
Yes
No
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