304 N Rosera Street
Old Hwy 141
Lena, Wisconsin
(920) 829-5525 tel
or 1-800-23MAPLE
(920) 829-5154 fax

New Agency Inquiries


NAME OF AGENCY:
STREET ADDRESS:
PO BOX:
CITY, STATE & ZIP CODE:
TELEPHONE NUMBER:
EMAIL:
HOW LONG HAS YOUR AGENCY BEEN IN BUSINESS?:
AGENCY ANNUAL PROPERTY/CASUALTY PREMIUM VOLUME?:
GENERAL MIX OF BUSINESS:
AUTO
COMMERCIAL
FARMOWNER
HOMEOWNER
MOBILEHOMEOWNER
OTHER
TOTAL
WHAT IS YOUR ESTIMATE OF WRITTEN PREMIUMS FOR MAPLE VALLEY MUTUAL PER PROGRAM FOR THE FIRST YEAR?
PROGRAM ESTIMATED WRITTEN PREMIUMS
FARMOWNERS
HOMEOWNERS
DWELLING
BOP
COMMERCIAL MULTI PERIL
UMBRELLA
TOTAL ESTIMATED PREMIUM FOR FIRST YEAR
DO YOU PLAN ON TRANSFERRING BUSINESS FROM OTHER COMPANIES IN YOUR AGENCY? IF YES, COMPANY AND REASONS:
HAVE ANY COMPANIES TERMINATED THEIR RELATIONSHIP WITH YOUR AGENCY IN THE LAST FIVE YEARS? (IF YES, EXPLAIN):
COMMENTS: