Agent Selection Questionnaire

Note: You may submit this information in any format you wish, as long as the information provided is complete. You do not need to use this form.

General Information About Your Firm

Your Firm’s Name:

Mailing Address:

Physical Location:



Name of Contact Person:


How many bank clients does your organization currently serve?

What is your approximate premium volume of bank business?

Account Management Team

Please attach a brief résumé for each person who would be handling our account. As a minimum, please be sure the following information is included:

-Name and position.

-Length of time in the insurance business.

-Licenses held.

-Length of time in your employment.

-Insurance work experience.

-Insurance designations earned.

-Specific experience with banks.

-Specific skills or expertise.

-Expected role on this account.

Please describe any specialized services that your firm has to offer, and that you feel would enhance your position in our evaluation.


List at least three bank clients or clients who have similar exposures.

1. Name:

Contact Name:


2. Name:

Contact Name:


3. Name:

Contact Name:


Any reference you provide may be contacted without notice to you.

Market Allocation

You may not approach an insurer or re-insurer until given permission to do so by us. Failure to comply with this restriction may automatically disqualify you.

List in the order of your preference the insurers you wish to utilize in the bid process.

First Selection – Insurer Name:

Lines of Coverage:

Why are you the best agency to approach this insurer?

Second Selection – Insurer Name:

Lines of Coverage:

Why are you the best agency to approach this insurer?

Third Selection – Insurer Name:

Lines of Coverage:

Why are you the best agency to approach this insurer?

Use additional sheets as needed. You may submit as many insurers as you wish.

Miscellaneous Information

Feel free to add any additional information you feel would be useful in our evaluation.

Pre-qualification Questionnaire Authorization

This pre-qualification questionnaire is submitted with my approval, and is true and factual.

Signature:__________________________________    Date:




Please return this form to:


Appendix Three: Bid Summary Matrix

Here is a list of issues to consider when reviewing your current insurance or comparing proposals from several insurers. I like to use a matrix with the issues below in the first column. Use the subsequent columns for the other insurers.

Go to for a free copy of this list in Microsoft Word format to make your job easier.

  Insurer A Insurer B Insurer C
Property Insurance      
Is Coverage Blanket or Specific?
Blanket Building & Personal Property Limit
Agreed Amount?
Special Perils?
Property Valuation
Flood Coverage
Flood Limitations
Flood Deductible
Earthquake Coverage
Earthquake Deductible
Property Deductible
Windstorm Deductible
Debris Removal
Building Ordinance
Improvements and Betterments
Personal Property of Others
Personal Property Off-Premises
Off-Premises Services
Boiler & Machinery
Accounts Receivable
Computer Equipment
Business Interruption
Business Income
Extra Expense
Blanket All Locations?
Agreed Amount
Maximum Period of Indemnity
Peril of Service Interruption
Loss of Rental Income
Occurrence CGL Form
Occurrence Limit
Aggregate Limit
Fire Legal Limit
Per Location Aggregate
Premium Basis
Auto Limit of Liability
Non-Owned Auto Coverage?
Drive Other Car Coverage
Employees as Insured on Auto Policy
Common Insurer for GL/Auto
Owned Watercraft or Aircraft
Pollution/Environmental Liability
Workers’ Compensation States
Employers’ Liability Limits
Umbrella Limits
Financial Institutions Fraud-Bond
On Premises
In Transit
Forgery and Alteration
Securities Forgery
Check Kiting
Claims Expense
Audit Expense Rider
Computer Systems Coverage – Fraud
Counterfeit Check
Counterfeit Currency
Destruction by Hacker
Destruction by Virus
Fraudulent Mortgage
Injury/Death Indemnity
Lost Instrument Bond
Trading Loss
Transit Cash Letter
Unattended ATM
Unauthorized Signature
Fax Wire Fraud
Telephone Wire Fraud
Management Liability
Directors’ and Officers’
Policy Limit
Entity Coverage Included in Policy Limit
Brokerage/Advisory Services
Employment Practices Liability
Trust E&O
Insurance Agent E&O
Coverage Trigger
Lender Liability Limit
Discovery Premium
Employment Practices
EPL Definitions
Are Above Limits Separate Limits or Do They Deplete The Aggregate?
Inland Marine
Machinery Breakdown
Workers’ Comp
Financial Institution Bond
Safe Depository
Directors’ and Officers’
Employment Practices
Internet Liability
Mortgage Impairment
Forced-Placed Property
Lenders Single Interest
Service Fees?
Agency Service Expectations
Frequency of Account Review
Claims Department
Producer Involvement in Account?
Extent of Loss Control Services
Phone/Email Return Policy?
Insurer Issues of Concern

Scott Simmonds, CPCU, ARM

Insurance Assurance Consulting

Phone: 207-284-0085

Consulting On, But Never Selling, Insurance