Formal Application

Date*
Date Format: MM slash DD slash YYYY
Prepared By:*
Preparer's Phone*
Person Preparing Email*
Enter Email Confirm Email
Consent*
I agree to provide accurate Information.
All information heretofore, herein or hereafter supplied to the Vesuvius Group Inc. by or on behalf of the applicant with respect to the information requested is and will be accurate and complete in all material respects.

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Legal Agency Name*
Trade Name If Differs From Legal Name
Agency Owners Name(s)*
First Last
Agency Owners Mobile Phone*
Additional Agency Owners Name(s)
First Last
Birthdate
Date Format: MM slash DD slash YYYY
Home Address Agency Owner*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Main Office Phone*
General Service Email
Office Fax*
Website
List Affiliation With Any Cluster Or Group
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Are there any other locations? If so please list.

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Agency Automation System
If you do not have one please state "none"
Do you have a Cyber Security Policy?*
Do you have a Cyber Security Protocol?*
Do you have rules procedures and policies in place to protect Client Data & Sensitive Information?*
Do you contract with 3rd party vendor to manage your computers & electronic data infrastructure?*
Is your agency compliant with the New York State Cyber Security Regulations?*
Do you have an active contract with a 3rd party document destruction company?*

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Business Practices
Has the agency or any former or current member, producer, principle, agent, employee ever had a license suspended or revoked by any carrier, company or any state insurance department?*
Has any legal or regulatory body ever sanction, censured, or penalized or otherwise disciplined the agency or any current or former office of the agency?*
Has the agency ever been subject to an insurance-related consumer initiated complaint or proceeding?*
Has an E&O Carrier ever denied claims, paid claims, or cancelled the agency's coverage?*
Has the agency or any of its officers ever filed a bankruptcy petition or been subject to involuntary bankruptcy petition?*
Are there any unsatisfied judgments, garnishments, or liens against the agency?*
Is the agency in debt to any insurance company?*
Have the officers of the agency ever been indicted for, convicted of, or pled guilty to any felony or misdemeanor other than a minor traffic offense?*
Has any officer or owner ever been arrested for any DWI/DWAI or any alcohol related driving infraction in the last 10 years?*
If yes to any of the above please explain.

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Total # Of Employees
# Of Producers*
# Of CSR's*
List Names Of All Licensed Staff
Please Provide Name, Phone#, Email or Extensions.
Upload All Active Licenses For Entity, Principles, Agents, Producers & Support Staff.
Drop files here or

Accepted file types: pdf.
Does your agency hold a non resident license?*
If so in what states?

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Banking to have ACH Deposited
Financial Institution
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Account #
Routing #
Upload Voided Check

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Upload E & O Carrier Policy
Drop files here or

Accepted file types: pdf.
Upload Prior 3 Years Corporate Entity Tax Returns
Drop files here or

Accepted file types: pdf.
Upload Prior 5 years Carrier Production Reports
Drop files here or

Accepted file types: pdf.

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Consent*
I agree
Brokering of business. It is understood the Vesuvius Group does not act in any way as broker to or for any partner agent or agency. It is understood that it is strictly prohibited to act in any way in the capacity as broker for any other person(s), agent or agency for compensation to any other person for or in connection to the placement of insurance policies with or connected to the Vesuvius Group.
Consent*
I agree to to have 3rd party conduct a background investigation.
Agency owners and principles are giving the Vesuvius Group Inc the right to conduct a standard legal background check.

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Agency Profile