ACORD 812 (2006/02)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 812 (2006/02)
Agency Questionnaire
This form is used to collect information that is commonly required of agencies to provide to
their carriers.
IDENTIFICATION SECTION Date (MM/DD/YYYY)
Month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
The name and address of the main agency location.
IDENTIFICATION SECTION Primary Contact
The primary contact that should be used by the carrier to contact the agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Producer's telephone number.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext)
Producer's fax number.
IDENTIFICATION SECTION E-Mail Address
Producer's e-mail address.
IDENTIFICATION SECTION Website Address
Producer's website address.
IDENTIFICATION SECTION Fiscal Year End
The date of the producer's fiscal year end.
IDENTIFICATION SECTION Nat'l Producer Number
The identifier assigned to an individual producer/agent/broker/agency by the NAIC.
IDENTIFICATION SECTION Contract Number
The producer's contract number with the carrier. This is also known as the Agency Code.
IDENTIFICATION SECTION FEIN
The producer's Federal Employer Identification Number.
IDENTIFICATION SECTION City Population
The population of the city of the main agency location.
E & O
Carrier
The name of the producer's Errors and Omissions carrier.
E & O
Expiration Date
The expiration date of the producer's E&O policy.
E & O
Limits - Ea Claim
The per claim limit on the producer's E&O policy.
E & O
Limits - Ea Occ
The per occurrence limit on the producer's E&O policy.
E & O
Limits - Aggregate
The aggregate limit on the producer's E&O policy.
AGENCY PROFILE
Name
The agency employee's name. Repeat the employee's information for each state in which
they are licensed.
AGENCY PROFILE
Title
The agency employee's title.
AGENCY PROFILE
E-Mail Address
The agency employee's e-mail address.
AGENCY PROFILE
Hire Date
The hire date of the agency employee.
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Section Name
Field Name
Field and/or Section Description
AGENCY PROFILE
Professional Designations
The description of designations the agency employee has received.
AGENCY PROFILE
P & C Agency License Number
The employee's P&C License Number.
AGENCY PROFILE
P & C Broker License Number
The employee's P&C Broker Number.
AGENCY PROFILE
Life & Health License Number
The employee's Life & Health License Number.
AGENCY PROFILE
State
The state the employee's license is applicable to.
AGENCY/BRANCH
OFFICES
Agency/Branch Name and Address
The name and address of additional agencies and branches associated with the main
agency.
AGENCY/BRANCH
OFFICES
Primary Contact
The primary contact that should be used by the carrier to contact the agency/branch.
AGENCY/BRANCH
OFFICES
Phone (A/C, No, Ext)
Producer's telephone number.
AGENCY/BRANCH
OFFICES
Fax No. (A/C, No, Ext)
Producer's fax number.
AGENCY/BRANCH
OFFICES
E-Mail Address
Producer's e-mail address.
AGENCY/BRANCH
OFFICES
Website Address
Producer's website address.
AGENCY/BRANCH
OFFICES
Fiscal Year End
The date of the producer's fiscal year end.
AGENCY/BRANCH
OFFICES
Nat'l Producer Number
The identifier assigned to an individual producer/agent/broker/agency by the NAIC.
AGENCY/BRANCH
OFFICES
Agency License Number
The producer's license number.
AGENCY/BRANCH
OFFICES
FEIN
The producer's Federal Employer Identification Number
AGENCY/BRANCH
OFFICES
City Population
The population of the city of the main agency location.
AGENCY/BRANCH
OFFICES
Carrier
The name of the producer's Errors and Omissions carrier.
AGENCY/BRANCH
OFFICES
Expiration Date
The expiration date of the producer's E&O policy.
AGENCY/BRANCH
OFFICES
Limits - Ea Claim
The per claim limit on the producer's E&O policy.
AGENCY/BRANCH
OFFICES
Limits - Ea Occ
The per occurrence limit on the producer's E&O policy.
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Section Name
Field Name
Field and/or Section Description
AGENCY/BRANCH
OFFICES
Limits - Aggregate
The aggregate limit on the producer's E&O policy.
AGENCY PREMIUM / MIX
OF BUSINESS
Company
List all carriers that the agency writes business with.
AGENCY PREMIUM / MIX
OF BUSINESS
Commercial Lines Volume
Enter the premium volume of the agency (in dollars) attributed to commercial lines policies
with the carrier.
AGENCY PREMIUM / MIX
OF BUSINESS
Personal Lines Volume
Enter the premium volume of the agency (in dollars) attributed to personal lines policies
with the carrier.
AGENCY PREMIUM / MIX
OF BUSINESS
Life & Health Volume
Enter the premium volume of the agency (in dollars) attributed to Life & Health lines
policies with the carrier.
AGENCY PREMIUM / MIX
OF BUSINESS
Loss Ratio
Enter the loss ratio with the carrier for the line of business.
AGENCY PREMIUM / MIX
OF BUSINESS
Interface - Download
Check this box if the carrier offers download for the line of business.
AGENCY PREMIUM / MIX
OF BUSINESS
Interface - Upload
Check this box if the carrier offers upload for the line of business.
AGENCY PREMIUM / MIX
OF BUSINESS
Interface - Real-Time
Check this box if the carrier offers real-time interface for the line of business.
AGENCY PREMIUM / MIX
OF BUSINESS
Interface - Website
Check this box if the carrier provides a website to process this line of business.
TECHNOLOGY
INFORMATION
Vendor Name
The name of your agency automation system vendor (e.g. Applied Systems, DORIS,etc.)
TECHNOLOGY
INFORMATION
System Name
The name of your agency automation system (e.g. TAM, FILESERVEROnline, etc.)
TECHNOLOGY
INFORMATION
Model
Enter the type of system model your agency is using (e.g. LAN, Local, ASP).
TECHNOLOGY
INFORMATION
Version
Enter the version of agency automation software that your agency is currently running.
TECHNOLOGY
INFORMATION
# Workstations
Enter the number of licensed workstations running the agency automation system
software.
TECHNOLOGY
INFORMATION
Minimum System Speed
The system speed in megahertz.
TECHNOLOGY
INFORMATION
Server Operating System
Enter the operating system that is running on your server.
TECHNOLOGY
INFORMATION
Browser
Enter the name of the internet browser used in your agency (e.g. Internet Explorer)
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Section Name
Field Name
Field and/or Section Description
TECHNOLOGY
INFORMATION
Browser Version
Enter the version of the internet browser used in your agency.
TECHNOLOGY
INFORMATION
User Group Name
Enter the name of the user group from the Agency Automation System.
TECHNOLOGY
INFORMATION
Active Member
Check Yes if you are an active member of the user group. Click No if you do not
participate in the user group.
TECHNOLOGY
INFORMATION
Do you pay technical support?
Check Yes if you are currently paying support fees for your agency automation system.
Click No if you are not paying support fees for your agency automation system.
TECHNOLOGY
INFORMATION
Describe other support
Describe any other support that your agency receives.
TECHNOLOGY
INFORMATION
Date last patch installed
Enter the date you last installed an update to your existing version of agency automation
system software.
TECHNOLOGY
INFORMATION
Date last version upgrade was
installed.
Enter the date you last upgraded to a complete new version of agency automation system
software.
TECHNOLOGY
INFORMATION
Agency staff that participate
regularly in day-to-day use of
agency automation system for
sales and/or service
Check the boxes next to all agency personnel that work in the agency automation system
on a day-to-day basis.
TECHNOLOGY
INFORMATION
Type of connection to the internet.
Check the box next to the type of internet connection used in the agency.
TECHNOLOGY
INFORMATION
Rating Vendor Name
If your agency uses a comparative rater, enter the rating system vendor name.
TECHNOLOGY
INFORMATION
Rating System Name
Enter the system name of the rating software used in the agency.
TECHNOLOGY
INFORMATION
Key Agency IT Contact(s)
Enter the name(s) of the key agency information technology contacts.
TECHNOLOGY
INFORMATION
E-Mail Address
Enter the e-mail address(es) of key agency information technology contacts.
GENERAL INFORMATION
Does every employee in your
agency have a work station with
access to: a) Internet, b) e-mail, c)
agency automation system.
Check Yes next to each question that applies to all workstations within your agency.
Check No next to each question that does not apply to all work stations within your
agency.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Does your agency input policy and
transactional detail for only
specific types of business?
Check Yes if you do not enter full detail in your agency automation system for all lines of
business.
GENERAL INFORMATION
Does your agency plan on
changing your agency automation
system vendor within the next
year?
Check Yes if you are planning on shopping for a new agency automation system within
the next year.
REMARKS
Remarks
Enter any additional comments you would like the carrier to receive.
AGENCY LICENSE
NUMBERS
Agency #
Enter the agency number used to identify the agency in the agency automation system.
Repeat the agency/branch information for each state in which the agency/branch is
licensed.
AGENCY LICENSE
NUMBERS
Branch #
Enter the branch number used to identify the branch in the agency automation system.
AGENCY LICENSE
NUMBERS
Agency/Branch Name
Enter the name of the agency/branch.
AGENCY LICENSE
NUMBERS
License Number
Enter the agency/branch license number.
AGENCY LICENSE
NUMBERS
State
Enter the state that issued the license number.
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