2022 Edition

 Questionnaire for Excess and
Surplus or Specialty Offices and Lloyd’s Qualified Brokers

This questionnaire provides information for the Excess and Surplus Lines, Specialty Offices and Lloyd’s Directories in The Insurance Marketplace. Please complete this form as fully as possible and return to Carolyn Pringle, Project Coordinator, The Insurance Marketplace, c/o The Rough Notes Company, Inc., P. O. Box 1990, Carmel, IN 46082; fax #: 317-816-1000; email: These listings are free.

1. Name of Company as it is to appear in publication:
  P.O. Box: City: State: Zip Code:
  Telephone: Toll-free:
  Please list complete address, telephone, toll-free and fax numbers of branch offices if they are to be included (Use a separate sheet of paper if needed.):
2. Do you operate as an Excess and Surplus Lines office?
  In which state(s) do you hold Excess and Surplus Lines licenses?
3. Do you accept and solicit business from other agents and brokers as a wholesaler?
4. Please list major excess and surplus or specialty lines offered through your firm and your carriers.
  Please list no more than six.
  Lines Carriers
5. Is your firm:
6. Are you a member of:

7. What is the scope of your operations?
8. Do you furnish both Lloyd’s and domestic facilities?
9. Do you place more than 25%, or at least $250,000, through the Lloyd’s market on a direct basis?
10. Do you have binding authority with a Lloyd’s broker(s)?
11. If yes, please list those Lloyd’s brokers:
The answers I have supplied are true and correct to the best of my knowledge. The Rough Notes Company may use them as the basis of our listing in the Excess and Surplus Lines Offices and Lloyd’s Qualified Representative directories in The Insurance Marketplace.
  (Name and title, please print clearly) (Date)
  Thank you for your assistance.


Marketplace advertising options:

(1) The basic National Market Directory, seen by agents countrywide, which contains our alpha coverage category listings, and a new table of contents organized by SIC codes.

(2) In any or all of five regional sections (Northeast, Midwest, Southeast, Southwest or Western) for agents in their corresponding geographical areas.

As a regional advertiser, you are eligible for free coverage listings, even though you might not otherwise qualify for the national directory.

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