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Insurance Agents & Brokers E&O Application
Desired Effective Date of Policy
Limits Desired
Retroactive Date of Current Policy
Deductible Desired
Agency Legal Name
DBA
Physical Address
City
*
State
*
Select a State
Alabama
Arizona
Arkansas
Colorado
Delaware
Florida
Georgia
Idaho
Illinois
Iowa
Kansas
Louisiana
Maine
Maryland
Michigan
Mississippi
Nebraska
New Mexico
North Carolina
Ohio
Oregon
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Washington
Zip
*
County
*
Year Owner Assumed Management
Number of Years Owner Has Been Licensed
Number of Agents
Number of Locations
Are all Locations controlled by Applicant?
Yes
No
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:
Retail Agent/Broker
Wholesaler
MGA/MGU/GA/PA
Other (Specify)
2. Please provide for past 12 months: (If new firm, estimate next 12 months)
P&C; Premium Volume
P&C; Commission
Life & Health Commission
Other Ins. Related Income
Specify Other Ins. Related Income
Estimate for next 12 months
P&C; Premium Volume
P&C; Commission
Life & Health Commission
Other Ins. Related Income
Specify Other Ins. Related Income
3. Please breakdown your total commission
Aviation
Bonds
Crop
Long Haul Trucking
Medical Malpractice
Ocean/Wet Marine
Prof. Liability (Incl. D&O;, EPLI, etc.)
Non-Standard Auto (Commercial)
Non-Standard Auto (Personal)
ALL OTHER COMMERCIAL LINES
ALL OTHER PERSONAL LINES
LIFE, ACCIDENT & HEALTH
4. Estimate the percentage of business the agency places with carriers that are:
Rated less than B+ by A.M. Best or are not rated
State Backed Insurance Risk Pools
5. Percentage of accounts that are directed billed?
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:
Been the subject of a complaint filed and/or disciplinary action by any insurance regulatory authority?
Yes
No
Had any policy or application for similar insurance declined, cancelled, rescinded or refused renewal?
Yes
No
Had any claim(s) made or suit(s) brought against them?
Yes
No
Been aware of any fact, circumstance or situation which may result in a claim being made?
Yes
No
8. Other Information:
Current E&O; Carrier
Limits
Deductible
Premium
9. Personal Information:
Name/Title
*
Date
Phone
*
Email
*
Submit
