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QUICK NOTE / QUICK QUOTE for Life & Health Agents
From the Errors & Omissions Experts
Please Complete For an E&O Premium Indication    (Not Applicable to "Captive" Agents)
  
  Agency Name: (or Individual Named Insured)
  Mailing Addresses: 
  City:
  State:  
  Zip Code: 
  Contact Name:
  Telephone Number:   
  Fax Number:
  Email Address:
  Effective Date:  
  Independent Agent/Agency Since?
  # Years Licensed
  Full Time / Part Time?
  Annual L&H Commission:
  Fees / Other Commissions? (Including New and Renewals)
  Other Income?
  Received From?
  Mutual Funds?  
  Currently Covered?  
  Series License Held? 
  Number of Persons with NASD License? 
  Limit:
  Deductible:
  Any Third Party Administrative Activities?  
  Currently Covered?  
  Property & Casualty Annual Premium if any:
  Number of P&C Employees
  Personal Lines:    %
  Commercial Lines:  %
  Broker:  %
1099- # Sub Agents
(Placing coverage thru your agency or contracts /  Annual Commission Dollars under / over $50,000) 		under $50,000
over $50,000
  Current Liability Limit: per claim
aggregate
  Deductible: per claim
aggregate
  Current E&O Carrier: carrier
  Retro-Active Date: (if any)  

 

 

professional insurance agents for nebraska & iowa  l  920 s 107th ave suite 305 l omaha ne 68114 l 402.392.1611 l  fax: 402.392.2228 l  cathy@pianeia.com