Agency Name (required):    Agency Email Address: 

Street Address: 

City (required):    State:    ZIP: 

Phone (required):    Fax: 

Decision Maker (required):     Role In Agency:   Agency Principal / Owner Personal Lines Manager Accounting Other

Person Evaluating Software:  Role In Agency:   Agent CSR Personal Lines Manager Other

Select the Auto Companies you represent.  To select multiple companies, hold down the Ctrl key as you click.

AAA** Affirmative Insurance Company of Michigan 21st Century Insurance Allied PC American Fellowship Auto-Owners* Bristol West (Reliance) CHUBB Cincinnati* Citizens Dairyland Employers / EMC Encompass (CNA) Fireman's Fund Frankenmuth Fremont General Accident Grange Great Lakes Hastings Mutual Infinity Property & Casualty (Great American) Lake States / Harleysville Merchants Mutual Mercury Insurance Michigan Automobile Placement Facility (MAIPF) Michigan Insurance Company Michigan Millers Northern Mutual Northpointe Ohio Casualty / West American Partners Insurance Pioneer Progressive* QBE Safeco Secura State Auto Titan Titan Affinity Travelers Victoria General Westfield Wolverine Mutual

Select the Home Companies you represent.  To select multiple companies, hold down the Ctrl key as you click.

AAA** Allied PC American Fellowship Auto-Owners / Home-Owners (HOIC)* Badger Mutual Brotherhood Mutual Chubb / Great Northern / Federal Pacific Indemnity Cincinnati Citizens Employers Encompass (CNA) Farmers / CIVIC P&C* Farmers and Merchants* Farmers Mutual Fireman's Fund First American Frankenmuth Fremont Grange Hastings Mutual Infinity Property & Casualty (Great American) Lake States / Harleysville Merchants Mutual Michigan Basic Property (MBPIA) Michigan Insurance Company Michigan Millers Northern Mutual Ohio Casualty / West American / American Fire Partners Insurance Pioneer State Mutual Safeco Secura State Auto Travelers / AETNA Westfield / Ohio Farmers / American Select Wolverine

Select the Fire Companies you represent.  To select multiple companies, hold down the Ctrl key as you click.

Where did you hear about us?  Please select an option Capital User's Referral Postcard from Capital MAIA GLAD Meeting Capital User's Referral Carrier Marketing Representative Management System Representative Convention Booth Brochure Internet Search Former Capital User

Agency Management System (if any):    Version: 

Current Pricing Software:    Annual Cost: 

Please send the software:  To Download   on CD.