Name *

First Name

Last Name

Cell Phone

(###)

###

####

Business Phone

(###)

###

####

Annual Premium Writings (YEAR END 2021) *

< $10 M

$11-18 M

$19-26 M

$27-40 M

> $40 M

Annual Premium Writings (YEAR END 2022) *

< $10 M

$11-18 M

$19-26 M

$27-40 M

> $40 M

Annual Premium Writings (YEAR END 2023) *

< $10 M

$11-18 M

$19-26 M

$27-40 M

> $40 M

Can you commit to attending two meetings per year, each meeting being two days in length and staying for the entire meeting session? *

Yes, I will commit.

No, I cannot commit.

Financial benchmarking is an important function of the group, are you willing to share your financials with your Peers? *

Yes

No

Are you willing to contribute to the group without reservation? For example: best practices, constructive feedback, participation in leadership, etc. *

Yes

No

Will you hold all discussion from the peer group in total confidence? *

Yes

No