Insurance Agents Errors and Omissions Quote

One Simple Form - takes only 2-3 Minutes!                                                 This Form for Insurance Agents Only

Name as it appears on License:

City:

Please list all owners / officers and their percentage of ownership

Name

Ownership %

Yrs Experience

Has E & O coverage ever been declined, denied, cancelled, non renewed including due to non-oayment of premium?

If your a New Agency, Please estimate your first years premiums

Total Annual Volume for all Lines

Last Year This Year Next Year

What is the percent of applicant's annual volume by line of coverage ? ( table Must = 100% total )

Do You have any Independent Contractors working for your Agency

Yes No

If Yes, Do You need coverage for any Independent Contract Agents

Has any individual listed or an employee thereof ever been subject to disciplinary action by any State Agency or Insurance Department

Have any claims or suites been made against applicant or any staff member in the last 5 years?

For Any Person Listed Above, are you AWARE of ANY circumstance, omission, error or offense which may result in a claim being made against the applicant or any of applicant's employees?

Liability Coverage Limit Requested:
($300,000, $500,000, $1 Million, etc.)

$ Preferred Deductible $

My preferred Method of Contact:

*

Email Call by Phone Fax

Fax # if chosen:

Thank you for filling out Our Quote Request Form!

Disclaimer Notice: - The premiums quoted are estimates based in the information you provided. If you have any questions or other pertinent information you feel necessary to properly quote your insurance Please feel free to contact our office at the number above for a personalized quote.

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