E&O Premium Indication Form

Premium Indication Form

This form can only be used to provide a premium indication. It does not replace the required carrier application. There is no guarantee a firm quote will be offered or coverage provided.

Contact Name*

Agency's Legal Entity Name*

Address*

City*

State*

Zip Code*

Phone*

Fax

Email*

Website

Is your website encrypted?

Yes
No

Date agency established (ex. 12/30/2007)

Number of Locations

Years of insurance experience

Years of experience as an independent agent

List any agency associations/alliances/clusters/aggregators to which you belong

Staff Size

(include ALL owners, principals, officers, producers, support staff, W-2s, 1099s, licensed and non-licensed employees, full-time and part-time)

Agency Employees

Full-Time Agency Employees: Licensed

Full-Time Agency Employees: Unlicensed

Part-Time Agency Employees (20 hrs or less): Licensed

Part-Time Agency Employees (20 hrs or less): Unlicensed

Independent Contractors

Full-Time Contractors: Licensed

Full-Time Contractors: Unlicensed

Part-Time Contractors (20 hrs or less): Licensed

Part-Time Contractors (20 hrs or less): Unlicensed

Property/Casualty premium volume $

Property/Casualty commissions $

Life/Health commissions $

Consulting/fees $

Percent of Business Placed

Directly with admitted carriers

Directly with surplus lines carriers/through surplus lines brokers

Through other agencies

Accepted from other agencies

As an MGA

As a TPA

Carrier information

List top 3 primary carriers and percentage of business placed with each:

Top Carrier

Top Carrier %

Second Carrier

Second Carrier %

Third Carrier

Third Carrier %

Percent rated B+ or better?

Product Lines

Personal Lines Percentage

% Non-Standard Personal Lines

% Standard Personal Lines

Life and Health Percentage

% Individual Life

% Group Life

% Individual Health

% Group Health

Commercial Lines Percentage

% Bonds

% Workers’ Comp

% Long Haul Trucking

% Medical Malpractice

% Crop

% Specialty Lines - please describe

Claims Information

Within the last five years, has anyone in your agency reported an incident or claim to your E&O carrier?

Yes
No

Within the last five years, have any of your E&O carriers paid a claim on your behalf? This would include any money paid for damages and/or expenses.

Yes
No

Agency Procedures/Operations

Please select all answers that describe your agency

We have an Employee Handbook
We have an office procedure manual
We have a tickler/follow-up system
We are paperless
We have date stamp mail
We have a staff training program
We have an exposure analysis checklist

What is your Agency Management System?

Most recent E&O loss prevention seminar attended

# of staff attended

Does 60% of your staff have an insurance designation? (CIC, CISR, CPCU, LUTCF, etc.)

Yes
No

Current E&O Coverage Information/Coverage Desired

Carrier

Expiration date

Retroactive date

Premium

Limits: Each loss

Aggregate

Deductible

Deductible type

Loss only
Loss plus expense

Years of continuous E&O

Desired limit

Desired deductible

Desired effective date

Additional Coverages Desired

Please select the additional coverage you are interested in.

Employment practices liability
Cyber liability
Commercial umbrella (will extend over E&O)

Are you interested in mutual funds (series 6 or 63 licensed)?

Are you interested in stocks, bonds, & mutual funds (series 7 licensed)?

Are you interested in Real Estate? If yes, please indicate the limit, deductible, number of licensed staff, and percent of agency income.

Name

First Last

Date