Insurance Agents & Brokers E&O

BASIC INFORMATION
Name of Agency
 Contact Name
Contact Email Address
Address: Street, City, State, Zip Phone Fax:

2. Date Established:

3. Number of years insurance agency experience:

4. Number of years continuous E&O coverage:

Staff Details

5. Full-Time Staff:  ; Part-Time Staff:
    Non-Employee (1099) Producers [Full-Time]: ; Non-Employee Producers [Part-Time]:
    Number of employees with professional designations (CIC, CPSR, CISR, CPSU, CLU):
    Number of employees with at least 3 years experience:

Agency Details

6. Please provide the following based on the last 12 months of operation:
    Agency P & C Premium Volume: $  
    Agency P & C commission income:$
    Agency Life/A & H commission income: $
    Consulting/Fees: $

7. Please indicate the percentage of premium volume derived from each line of business listed below.

PERSONAL LINES COMMERCIAL LINES
Auto (Standard) Auto (Other than Long Haul Trucking)
Auto (Non-Standard)/Motorcycles Long Haul Trucking
Homeowners/Umbrella Business Owners' Policy
Personal Marine General Liability & Property (Non-BOP)
Other (Describe): Workers' Comp
(Non-retrospective Rated)
LIFE, ACCIDENT & HEALTH Workers' Comp (Retrospective Rated)
Individual Life Bonds
Individual Accident & Health Crop/Animal Mortality
Group Life Aviation
Group Health Inland Marine/Ocean Marine
Financial Products (series 6) Professional Liability/Med-Mal
Other (Describe):

TOTAL:

8. What percentage of total income comes from one or more of the following: loss control inspection or safety consulting, property appraisal for a fee, third party administration services, employee insurance benefit consulting, estate insurance planning, consulting for a fee or placement of pre-paid legal servicesmemberships? %

9. Number of companies represented with B + or lower A.M. Best Rating:

10. Company Direct Bill: %

11. Percentage of business placed with carriers: Direct %; Broker %

12. Percentage of business placed with carriers:  Non-Admitted:%;   Admitted:%

13. Percentage of business placed: Retail%; Wholesale%

14. Need Mutual Fund or Real Estate endorsement? Yes  No
If yes, what is the commission income derived from these activities? $

15. List all carriers business is placed with, including those accessed via broker, wholesalers or MGA:

16. Business you placed as a(n): Agent:%; Broker:%; Surplus lines agent:%; MGA:%

17. Percentage of: Personal Lines: %; Commercial Lines: %; Life, A&Health: %

Office Procedures

18.Office Procedures
a. Are copies of binders mailed to insured and/or the company promptly? Yes  No
b. Is there a procedure for documenting phone conversations? Yes  No
c. Is a policy expiration list maintained? Yes  No
d. Are all policies and endorsements for accuracy? Yes No
e. Does agency have a diary/suspense system? Yes No
f. Does applicant have an Office Procedures Manual? Yes No
g. Does applicant document a client's refusal to accept coverage/limits limitations? Yes No
h. Does agency utilize a computerized production and accounting system? Yes  No
i.  Is incoming mail date stamped? Yes  No  
j. Yes Are binders confirmed in writing? Yes  No 

 

Coverage Details

19. Name of current E&O Carrier:

20. Current- Limits: $; Deductible: ; Premium:

21. Desired- Limits:$; Deductible:; Retro Date:

22. Effective Date:

 

Claims

23. How many E & O claims in the past 5 years: 
      Has the Applicant been the subject of disciplinary action or investigation as a result of professional        
      activities? Yes  No    
      Does the Applicant have any knowledge of any potential errors or omissions claim(s)? Yes  No  

24. Have employees attended any E&O loss prevention seminars or other industry related education courses
      within the past 2 years?  Yes  No
        If so, who Sponsored: IIAA ; PIA;Other:

 

This document is a non-binding indication question sheet and is subject to receipt of a fully completed application and supporting documents prior to firm quotations being rendered by the company.  Upon review of these documents, the company reserves the right to change the terms indicated via this questionnaire or decline to render terms for this coverage.

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