Interested Agency Survey
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Interested Agency Survey

Physical Address:
City:
 		State:
 		Zip:
How long has your agency been in operation? If this is a new agency, please provide your background.
Current Total Annual Premium Amount of Workers’ Compensation Written
What type of workers’ compensation risks does your agency handle? (nature of business, avg premium size, existing businesses, new ventures, etc.)
What workers' comp companies are you currently contracted with?
Why are you interested in writing with LCTA Workers’ Comp?
If contracted, what type of new business commitment are you willing to make for the first year?
How did you hear about LCTA Workers’ Comp?