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?

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

OIA Premium Indication Form

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