Become a Producer - Patriot General Agency, LLC

Territory

marketing@patriotmga.com

Business Name

Telephone # – Include Area Code

Fax # – Include Area Code

City

State

ZIP Code

Mailing City

Mailing State

Mailing ZIP Code

Company Status

Years Established

Years In Industry

Number of Producers

Number of Employees

Number of Locations

Are You Licensed in Any Other State?

E&O Limits

Preferred Comparative Rater

FSC

ITC

EZLynx

Name

Title

Phone

License #

% Ownership

Number of DOI or BBB Complaints in Last 5 Years

Have You or Your Firm Ever Been Denied by a Prior Carrier?

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