PIA/CNA E&O Quick Quote Application

Please complete the form below to receive a preliminary quotation for E&O insurance. A PIA producer will contact you shortly to assist you.

If you will be unable to complete this form in one sitting, please download our Quick Quote PDF which may be saved to your computer and completed in multiple sessions.

Please note: When using our Quick Quote PDF, your computer must be equipped with Adobe Reader Version 8 or above in order to SAVE your answers to your computer. Download the newest version of Adobe Reader (free) here before you begin to complete the Quick Quote PDF: http://www.adobe.com/products/reader/

Questions? Call PIA at 1-800-PIA-6900 ext. 362 or 703-518-1362 or email us at EandO@pianet.org

Name of Agency

Date Established

Contact Name

Phone

Fax

Email Address

Mailing Address:

Street or PO Box

City

State

Zip Code

Number of years insurance agency experience

Number of years principals licensed

Number of years continuous E&O coverage

Current E&O Carrier

Current Retro Date

Policy Eff. Date

Limits currently carried

Current deductible

Premium

Please provide the the following based on the last 12 months of operations:

Agency P&C premium volume

Agency P&C commission income

Agency Life/A&H commission income

Consulting/Fees

Total Staff Size:

Full Time

Part time (including Owners, Officers, Partners, CSR's, etc)

In the past 5 years, number of E&O claims

Number of closed claims in the past 5 years

Dollar Amount paid (including claim expense)

Any current open claims?*

Yes*

Has your E&O been cancelled or non-renewed in the past five years?*

Yes*

Has the Applicant been the subject of disciplinary action or investigation as a result of professional activities?*

Yes*

Does the Applicant have any knowledge of any potential error and omissions claim(s)?*

Yes*

* If you answered yes to any of the above four questions, please provide an explanation with details.

Percentage of business placed with carriers:

Admitted

Non-admitted

Business you placed as a:

Agent

Broker

Surplus Lines Agent

MGA

--Please indicate the dollar amount OR percentage of Applicant's premium volume derived from each line of business listed below.--

Personal Lines:

Auto (Standard)

Auto (nonstandard)/Motorcycles

Homeowners/Umbrella

Personal Marine

Other (Describe)

Life, Accident & Health:

Individual Life

Individual Accident & Health

Group Life

Group Health

Financial Product (Series 6)

Commercial Lines:

Auto (other than long haul trucking)

Long Haul Trucking

Business Owners' Policy

General Liability & Property (non-BOP)

Workers' Comp (Non-retrospective rated)

Workers' Comp (Retrospective rated)

Bonds

Crop/Animal Mortality

Aviation

Inland Marine/Ocean Marine

Professional Liability/Medical Malpratice

Other (Describe)

Date