Sell your Insurance Agency Franchise

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All About You

Your Full Name

First Middle Last

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Country of Citizenship

Insurance Background

Are you a licensed agent?

Are you currently affiliated with a carrier?

Please list the carriers with which you are currently affiliated.

Enter the names of all carriers with which you are affiliated, separated by commas.

Have you had an Appointment Revocation in the last 5 years?

Please list the carriers for which you've had appointments revoked.

Enter the names of all carriers for which you've had appointments revoked, separated by commas.

Are you currently or have you been involved in litigation in the last 5 years?

Have you declared Bankruptcy in the last 7 years?

Have you ever been convicted of a felony?

Please explain your felony conviction(s):

Your Business

How many years have you been in business?

How many locations do you currently own?

First Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Second Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Third Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Fourth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Fifth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Sixth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Seventh Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Eighth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Ninth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Tenth Location

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 11

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 12

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 13

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 14

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 15

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 16

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 17

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 18

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 19

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Location 20

Street Address Address Line 2 City State ZIP Code

License Number

Please enter this location's insurance license number.

Average Monthly Sale Volume

Please indicate the average monthly sale volume for this location.

Agents at this Location

Please enter a number greater than or equal to 1.

Please indicate the number of full- and part-time agents at this location

Additional Locations

Even More Locations

Please enter the addresses, license numbers, agent counts, and monthly sales volume figures for each additional location here. Please separate your entries with "---".

Your Existing Infrastructure

Do you currently use an Agency Management solution (e.g. ITC InsurancePro, AgencyMatrix, etc.)?

Which agency management system does your company use?

Please enter the name of your agency management software solution

Does your business currently use an Electronic Signature solution (e.g. Formstack, Adobe Sign, etc.)?

What Electronic Signature solution does your business utilize?

Do you currently have a Rating System implemented (e.g. ITC TurboRater, SureFyre, Zywave, etc.)?

What rating system does your business utilize?

Wrapping up

How soon are you looking to complete a transaction and sell your agency(s)?

Sell your Insurance Agency Franchise

All About You

Insurance Background

Your Business

First Location

Second Location

Third Location

Fourth Location

Fifth Location

Sixth Location

Seventh Location

Eighth Location

Ninth Location

Tenth Location

Location 11

Location 12

Location 13

Location 14

Location 15

Location 16

Location 17

Location 18

Location 19

Location 20

Additional Locations

Your Existing Infrastructure

Wrapping up

About

L.A. Insurance

Insurance

Policyholders

Legal

Carriers

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