Berkley Net Underwriters, LLC
Please complete the form in its entirety and return to us via email, fax, or postal mail.
E-Mail – agents@berkleynet.com
Fax – 866-326-1339
Postal Mail –
Berkley Net Underwriters – Marketing Office
Attn: Brian Douglas
4504 Glen Pointe Way
Smyrna, GA 30080
Confidentiality
All material received will be treated as confidential. Upon discussion with the agency after
reviewing the information, we may recommend discussion with or referral to a Berkley Net partner
or other W R Berkley Company. Only by mutual consent will such information be shared with any
other affiliate.
Agency Information
Legal Agency Name
DBA
FEIN
Entity Type
State Registered
Physical Address
City
State
Zip
City
State
Zip
Phone
Fax
Mailing Address
Website
Agency Management System
Contact Information
Primary Agency Contact for Appointment
Email Address
Primary Marketing Contact
Email Address
Primary Licensing Contact
Email Address
Primary Accounting Contact
Email Address
Primary Claims Contact (if applicable)
Email Address
Does Agency Have Multiple Offices (Yes/No)
If yes, in what City(s), State(s) (you may attach a separate list)
Agency Volume Information
Current Total Agency Premium Volume $
Commercial Lines P&C
%
Current Total Workers’ Compensation Premium Volume $
Current Number of Monoline Workers Compensation Markets with direct contract?
Number of Monoline Workers’ Compensation Markets added past 18 months?
Number of Monoline Workers’ Compensation Markets terminated past 18 months? (if any, please
explain)
Top 3 Workers Compensation Markets
Market
Premium Volume
3yr Loss Ratio
Commission
Market
Premium Volume
3yr Loss Ratio
Commission
Market
Premium Volume
3yr Loss Ratio
Commission
Top 2 Package Markets
Market
Total Volume
WC Volume
WC Commission
Market
Total Volume
WC Volume
WC Commission
Agency Marketing Focus
What state(s) do you primarily market business?
Account Profile – Workers’ Compensation
Premium Size
Less than $5,000
%
Primary Market
$5,000 - $50,000
%
Primary Market
$50,000 - $100,000
%
Primary Market
Over $100,000
%
Primary Market
New Ventures/No Prior Coverage =
Avg. new venture account size
% of monthly new business
Primary Market
Accounts with multi-state exposure =
Avg. multi-state account size
% of monthly new business
Primary Market
Type of Accounts – Risk Selection
Construction
%
Primary Market
Hospitality/Service
%
Primary Market
Manufacturing
%
Primary Market
Office/Professional
%
Primary Market
Transportation
%
Primary Market
Where would you likely place an account with an experience mod over 1.50?
Approximately how many accounts has the agency had to place in the Assigned Risk pool in the
past 12 months?
# Accounts
$ Premium
Any current special programs or target industries within the agency? If so, please discuss.
Any specific areas or classes of business you are having difficulty placing currently? If so, please
discuss.
Agency Preferences
What are the most important characteristics for your agency in a workers compensation market?
Do you currently work with other workers’ compensation products that primarily focus on internet
distribution? If yes, please describe your office’s success in working with.
How would you improve the operations and relationship with your current workers’ compensation
markets?
Any other information you’d like to share?