Due Diligence Questionnaire Form - Affiliate Book Purchase Evaluation

Acquisition Due Diligence Form

Affiliate Book of Business Purchase Evaluation Information
Agency Corporate & Ownership Information
Agency Name*
Full Legal Corporate Name
DBA (if any)*
DBA name if different from legal corporate name
Owner/Principal Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Type of Business Entity*

CorporationLLCSole ProprietorOther
Business & Financial Information
Does the Agency/Owner's Total Book of Business contain policies which are not placed through Panorama?*

YesNoOther
If Yes, please specify carriers, PL and CL % and approximate premium volume.
Please provide a Book of Business Report for the polices which are not placed through Panorama (if any)

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Do you use an Agency Management System?*

YesNoOther
If Yes, please provide AMS Name and monthly cost
Do you have any E&O Claims threatened, pending or in process currently?*

YesNo
If Yes, please provide information:
Do you write Employee Benefit lines of insurance (Group Health, Dental, Vision, Life & Disability)*

YesNo
If Yes, please provide information:
Financial Statements: Please provide Financial Statements for your Agency (Balance Sheet & Income Statement) less then 90 days old

Can be Excel files, PFF or Word documents
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Bank Statements: Please provide the Agency's last 2 months' bank statements*

PDF files
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Tax Returns: Please provide the Agency's most recent federal and state tax returns

PDF files
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Corp Filings: Please provide the Agency's Articles of Incorporation/Organization

PDF files
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If there are any documents that you cannot provide, please explain below:
Do you plan to work for a year or more to help with retention?
Please let us know if you want to continue to be involved
Are there any Agency employees you want us to consider hiring?
If there is any other information related to the agency, or the questions, information or documentation requested on this form, that you think important, please tell us:
What is your desired date of purchase/closing

MonthDayYear
Please note that we may not be able to accommodate your request
Certification, Authorization and Disclaimer
By signing and submitting information in this questionnaire form, I represent and warrant that the information provided is accurate and complete to the best of my knowledge. I authorize Panorama Insurance Associates, Inc. to verify the details I have provided. I acknowledge that the submission of the information is for the purpose of having Panorma evaluate whether to proceed to make a purchase offer for my book of business and does not obligate Panorma to make any such offer or proceed with a purchase.
Date of Submission*

MonthDayYear
Today's Date
Signature*

Clear
Should be Empty:

Acquisition Due Diligence Form

Agency Corporate & Ownership Information

Business & Financial Information

Certification, Authorization and Disclaimer