E&O Coverage for Insurance Agents

Insurance Agent's E&O Quote Request:

Agency Name:

Contact Name:

Address:

City:

State:

Zip Code:

Phone:

Date Agency Established:

Email:

Additional Agency Info:

Any changes in agency ownership in the past 3 years?YesNo

Any fines/disciplinary actions in the past 5 years?YesNo

Any mergers/acquisitions in the past 3 years?YesNo

Any E&O claims in the past 5 years?YesNo

Does the agency have written procedures to be used by all staff?YesNo

Does the agency receive income from any additional services?YesNo

Description of income received from additional services:

Percent of volume placed with unrated carriers or carriers rated below B+:

Minimum financial standard you require for your carriers:

Percent of business that is direct billed by your carriers:

Total Annual Volume and Commission:

P&C Premium Volume Last 12 Months:

P&C Commissions Last 12 Months:

Life & Health Commissions Last 12 Months:

P&C Premium Volume Next 12 Months:

P&C Commissions Next 12 Months:

Life & Health Commissions Next 12 Months:

Market Breakdown - Please provide the dollar amount OR percent of total volume (must total 100%):

Accident & Health - Group:

Accident & Health - Individual:

Annuities:

Auto - Commercial, Other than Long Haul Trucking:

Auto - Non-Standard:

Auto - Standard:

Aviation:

Bonds:

Business Owner's Property:

Crop:

General Liability & Property - Non-BOP

Homeowners/Umbrella:

Life - Group:

Life - Individual:

Marine - Inland:

Marine - Ocean:

Marine - Personal:

Mutual Funds:

Pension Plans:

Professional Liability/Medical Malpractice:

Trucking - Commercial, Single Owner/Operator:

Trucking - Commercial, Fleet:

Workers' Compensation:

Other - Please Describe:

Business Placement Percentage (must total 100%):

Directly w/admitted P&C carriers or their MGAs (not brokered):

With admitted life, accident and health carriers or their GAs:

Brokered to admitted P&C carriers through others/wholesalers:

Directly or through a broker with non-admitted carriers:

As an MGA or underwriter, not through an MGA but "as" an MGA:

Directly or through a broker w/risk assuming entities other than insurance carriers:

Top 3 Insurance Carriers Represented:

Carrier Name:

% of Volume Placed:

# of Years:

Lines Placed:

Carrier Name:

% of Volume Placed:

# of Years:

Lines Placed:

Carrier Name:

% of Volume Placed:

# of Years:

Lines Placed:

Number of Owners, Partners and/or Principals:

Licensed:

Unlicensed:

Full-Time:

Part-Time:

Attending E&O Risk Mgmt.:

With Designations:

Number of All Other Staff, Excluding Above:

Licensed:

Unlicensed:

Full-Time:

Part-Time:

Attending E&O Risk Mgmt.:

With Designations:

Current E&O Policy Details:

Carrier Name:

Limits:

Deductible:

Retro Date:

Expiration:

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E&O Coverage for Insurance Agents