Become an Insurance Agent with The Hartford

PRE-SCREENING QUESTIONNAIRE


GENERAL INFORMATION


PRIOR APPOINTMENT WITH THE HARTFORD



EMPLOYEE INFORMATION


AGENCY PRODUCTION

$
 
%
 
%

Commercial Lines Insurance

 
$

 
 
$

 
 
$


Personal Lines Insurance

 
$

 
 
$

 
 
$


CERTIFICATION

By my signature below, I certify that the information provided herein is complete and accurate. If an appointment is offered to me and my agency, I understand that a background check may be conducted on me and all staff members in my employ as part of the appointment process.

I confirm that the production statement, carrier financial and loss statements that accompany this application are only for my agency and that these reports completely and accurately represent my agency's production for the most recent three calendar years.