American Millennium Insurance Company (AMIC)

Contact Name(required)

Contact Title

Agency/Company Name(required)

Address(required)

Primary Location of Program

Policy Limits

Type of Program (check all that apply)

Trucking

Taxi

Limo

General Liability

WC

Other

If other, please enter type

Coverage Types (check all that apply)

Full coverage

Liability only

Physical damage

Cargo

Other

Current or New Opportunity/Program

Existing Program

New Opportunity

Age of Current Program

Loss History

Claims Handling

AMIC

TPA

Policy Issuance

AMIC

MGA

Other

If other, please enter

Policy Management System Used

Distribution System Used

Filings Needed

Projected Value of Opportunity