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QUICK NOTE / QUICK QUOTE
For An E&O Premium Indication
From the Errors & Omissions Experts
Please complete the following form or
download & complete
the application and return it to PIA.
All fields are required to obtain
a proper premium indication.
This information will be used to predict a premium only,
and is not an offer of a bind-able proposal.
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| Agency Name: |
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Federal ID: |
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Mailing Addresses: |
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City: |
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| State: |
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| Zip Code: |
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Contact Name: |
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Telephone Number: |
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| Fax Number: |
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Email Address: |
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| # Years in Business: |
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Effective Date: |
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Retro Date: |
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or Full Prior Acts: |
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List any agency Associations you are currently a member of: |
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Total Agency Annual Premium Volume:
(Property & Casualty Only) |
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Breakdown of your Commission Income |
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Personal Lines: |
% |
| Commercial Lines: |
% |
| Life & Health: |
% |
What is the total # of ALL Persons in Your Agency?
(# of Persons includes ALL owners, officers, producers, W-2's, 1099's;
both licensed & non-licensed employees, FT or PT) |
Full Time:
(Over
20 hours per week is considered Full Time)
Part Time:
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| Loss Control: |
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# of Staff attended E&O Seminar
in Past 15 months (from effective date of policy) |
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Number of Staff with Recognized Designations (CIC, CPSR, CISR,
CPCU, CLU, LUTCF, ACSR, etc) |
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| Do you have an acceptable Office Procedures
Manual? (not employee manual,
must be actively used) |
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| Do you have an acceptable Exposure Analysis
Checklist? (not employee
manual, fax to PIA for credit) |
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What % of your business is placed through or
from other
agents/brokers? (including surplus lines) |
(i.e. 10%) |
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How many E&O claims/incidents has your agency had over the last 5
years? |
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Current E&O Limit: |
per claim
aggregate |
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Deductible: |
per claim
aggregate |
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Your Expiring E&O Premium / Carrier: |
premium
carrier |
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