PREMIER GROUP INSURANCE CONFIDENTIALITY AGREEMENT – AGENCY QUESTIONNAIRE

This non-disclosure agreement (Agreement) is between Premier Group Insurance, Inc., (PGI) and (Agent). Whereas PGI and Agent wish to exchange certain information pertaining to the operations and contractual obligations of PGI and its independent contractors, these two parties hereby agree to the following conditions:

1. PGI will provide Agent with an original copy “Draft” of its standard Agency/Agent contract (contract). In addition, PGI will provide Agent with additional information, both orally and in writing, as to the operations and benefits of becoming an Independent Contractor with PGI.

2. Agent agrees not to share this information with any third parties not explicitly approved by PGI and to use reasonable and practical care to protect and maintain possession of the contract and any other materials provided to Agent by PGI. This applies not only to all original documents, but to all copies that may have been made by or supplied to Agent.

3. Upon request of PGI, Agent will return all documents, materials, and notes both originals and copies to PGI within 15 days of the request.

4. In the event of a breach or threatened breach of this Agreement, PGI shall be entitled to preliminary and final injunctions, in addition to any other rights and remedies available to it at law or in equity.

5. The validity and performance of this contract are governed by the laws of the State of Colorado.

6. This Agreement is binding upon the directors, officers, employees and agents of each party and will continue indefinitely, with the obligations of confidentiality surviving the termination of this Agreement.

*All Information is held in strictest confidence.
Have Questions? Reach out to DavidC@PGIAgents.com

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Planned Business Location (retail, office space, suite, home based) *

Tell us about your background (Insurance, Financial, Tax Prep., what you did before…) *

Describe Your Present Situation (Captive or Independent Agency…Motivation for exploring options?) *

Please describe your typical Customer Profile *

What are your most important needs? *

What is Your Timeline in Making a Decision: *

Present Agency Written Premium (Captive/Independent)

Trailing 12 Month Commissions (Captive/Independent)

Present Agency Information (PL%- VS - CL% SPLIT) *

Present Agency Information: (Lead Carriers) *

Present Agency Information: (States Licensed) *

Plans going forward (Estimated Premium Year 1, 2, 3:)

Plans going forward (Estimated Commission Income Year 1, 2, 3) *

Plans going forward (Primary Sales Initiatives)

Additional Information: e.g., non-completes, previous criminal convictions, carrier terminations,bankruptcy, etc…

PGI Representative *

E-Signature *

Date *

Submission Validation

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Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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8089 South Lincoln St., Suite 300
Littleton, CO 80122
720-457-1101