Market Survey

Agency Name as Listed on License:

Other Entities to be listed under contract:

List any Branch offices to be included in this contract:

Total Agency Commercial Premium Volume:

Current Primary WC Carriers:

Agency Management System (Version and Series):

WC Volume: Do you Upload?

From the categories below, please indicate the percentage of your WC volume they compose:
Transportation	Wood Products	Agribusiness
%	%	%
Construction/Excavation	Oil & Gas	Manufacturing
%	%	%

Specify any other class(es) not listed above and percentage:

Please list any other states besides your state of domicile where you will solicit:

Agency Principal:		THIS IS NOT A CONTRACT Completion and submission of survey *does not* gaurantee a contract will be issued to your agency.
Title:
Date:	May 16, 2012