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Membership
- Renew Membership
- Become a Member
Agent Resources
Product & Services
Resource Center
HR Solutions
News & Events
Learning Portal
- Course Schedule
Partners
- Company Partners Benefits
About OIA
- Best Workplaces in Ohio
- Center of Our Universe

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OIA Premium Indication Form

Please fill out the below to get started.

Alternatively, you can download the PDF version here.

OIA 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?
- None
- AMS
- Applied
- SIS
- Doris
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
Date Format: MM slash DD slash YYYY

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Ohio Insurance Agents Association, Inc.
175 South Third Street, Suite 940
Columbus, OH 43215

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