Insurance Agents & Brokers E&O Application

If agency established or assumed ownership less than 3 years ago, must include resume of owner(s).

1. Please list the percentage of business placed as:

2. Please provide for past 12 months: (If new firm, estimate next 12 months)

Estimate for next 12 months

3. Please breakdown your total commission

4. Estimate the percentage of business the agency places with carriers that are:

5. Percentage of accounts that are directed billed?

6. Does the agency utilize an:

Automated calendar/diary system
Automated accounting/Invoice system
Automated agency management system
Online carrier system

7. During the past 5 years, has the Applicant, any other predecessor in business, past or present owner, director, officer, partner or principal:

8. Other Information:

9. Personal Information: