Premium Indication Form

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Swiss Re Corporate Solutions Capacity Insurance Corp
For Exclusive use only for Members of The Agency Collective Alliance - Premium Indication
Contact Name
Agency's Legal Entity Name
Address
City
State
Zip Code
Email
P&C new & renewal premiums written annually
Life and A&H new and renewal commissions
Annual Premium Percentage from Commercial Lines
Annual Premium Percentage from Personal Lines
Total Agency Staff
Current Carrier
Carrier Limits
Carrier Deductible
Carrier Policy Retro Date
Carrier Premium
Policy Effective Date
Comments
This form is used to provide a non-binding, premium indication based on preliminary information provided and is not intended to be a firm quote for acceptance of insurance coverage. To determine your qualification for a firm quote, we will need a fully completed Swiss Re application, along with a 5-year loss run.
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