PIA E&O Quick Quote Application |
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| Please complete the form below to receive a preliminary quotation for E&O insurance. A PIA producer will contact you shortly to assist you. |
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| You must agree to the Terms of Use to complete this Online Quick Indication Quote Application. If you have not done so already, please click here now to read them. |
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| Name of Agency (required) |
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| Date Agency Established |
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| Contact Name (required) |
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| Phone (required) |
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| Fax |
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| Email Address (required) |
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| Mailing Address: |
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| Street or PO Box (required) |
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| City (required) |
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| State (required) |
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| Zip Code (required) |
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| Number of years of insurance agency experience |
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| Number of years continuous E&O coverage |
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| Name of current E&O carrier |
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| Current retroactive date |
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| Policy effective date |
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| Limits & Deductibles: |
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| Limit - each loss |
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| Limit - aggregate |
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| Deductible - each loss |
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| Deductible - aggregate |
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| Current premium |
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| Please provide the following based on the last 12 months of operation. |
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| Agency P&C premium volume |
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| Agency P&C commission income |
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| Agency Life/A&H commission income |
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| Consulting/Fees |
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| Total full time staff (including Owners, Officers, Partners, CSR's, etc.) |
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| Total part-time staff (including Owners, Officers, Partners, CSR's, etc.) |
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| Full time, non-employee producers (1099 producers) |
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| Part-time, non-employee producers (1099 producers) |
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| Number of employees with professional designations (CIC, CPSR, CISR, CPCU, CLU) |
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| Number of employees with at least 3 years experience |
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| In the past 5 years, number of E & O claims |
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| Has the Applicant been the subject of disciplinary action or investigation as a result of professional activities? |
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| Does the Applicant have any knowledge of any potential errors or omissions claim(s)? |
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| If you answered yes to either of the two questions above please provide an explanation with details. |
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| Have any employees attended any E&O loss prevention seminars or other industry related education courses within the past two years? |
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| If yes, who sponsored these? (PIA, IIABA, etc.) |
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| 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 services memberships? |
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| Number of companies represented with B+ or lower A.M. Best Rating |
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| Company direct bill |
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| Percentage of business placed with carriers: |
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| Directly |
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| Broker |
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| Percentage of business placed with carriers: |
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| Admitted |
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| Non-admitted |
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| Percentage of business placed: |
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| Retail |
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| Wholesale |
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| List all carriers business is placed with, including those accessed via broker, wholesalers or MGA. |
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| Business you placed as a: |
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| Agent |
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| Broker |
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| Surplus lines agent |
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| MGA |
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| Please indicate either the dollar amount or percentages of the Applicant’s premium volume derived from each line of business listed below. (If using percentages, the total of all lines should equal 100%.) |
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| Personal Lines |
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| Auto (Standard) |
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| Auto (Non-standard)/Motorcycles |
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| Homeowners/Umbrella |
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| Personal Marine |
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| Other (describe) |
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| Life, Accident & Health |
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| Individual Life |
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| Individual Accident & Health |
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| Group Life |
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| Group Health |
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| Financial Products (series 6) |
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| Commercial Lines |
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| Auto (Other than Long Haul Trucking) |
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| Long Haul Trucking |
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| Business Owners’ Policy |
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| General Liability & Property (Non-BOP) |
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| Workers’ Comp (Non-retrospective Rated) |
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| Workers’ Comp (Retrospective Rated) |
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| Bonds |
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| Crop/Animal Mortality |
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| Aviation |
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| Inland Marine/Ocean Marine |
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| Professional Liability/Medical Malpractice |
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| Other (describe) |
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| Office Procedures (loss control credits are given in this area) |
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| Are copies of binders mailed to insured and/or the company promptly? |
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| Is there a procedure for documenting phone conversations? |
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| Is a policy expiration list maintained? |
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| Are all policies and endorsements checked for accuracy? |
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| Does agency have a diary/suspense system? |
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| Does applicant have an Office Procedures Manual? |
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| Does applicant document a client’s refusal to accept coverage/limits limitations? |
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| Does agency utilize a computerized production and accounting system? |
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| Is incoming mail date stamped? |
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| Are binders confirmed in writing? |
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| Thank you for completing the PIA E&O Quick Quote Application. Please click the Submit button below to send this application to your local PIA agent. Should you want to print this form, please do so prior to clicking Submit. Thank you for supporting PIA. |
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