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Home > Errors Omissions > Property & Casualty Insurance Agents and Brokers E & O Application

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Property & Casualty Insurance Agents and Brokers E & O Application

Click Here to Download the Application

Personal Information

Applicant’s Legal Entity Name

Required

First Name

Required

Last Name

Required

Street

Required

City

Required

State

Required

ZIP / Postal Code

Required

No. of Locations

Required

State(s)

Required

Primary Phone Number

Required

Website Address

Required

E-Mail Address

Required

Agency is a

Required

Corporation
Sole Proprietorship
Partnership
LLC
Other

Date Entity Established

Required

(If less than three years ago, you must attach a resume and business plan.)

Number of years industry experience of agency principal(s)

Required

Have you had any acquisitions, mergers or cluster arrangements within the past five (5) years?

Required

Yes
No

Current E&O carrier

Required

Retroactive Date

Required

Desired Eff. Date

Required

(ATTACH COPY OF CURRENT E&O DECLARATIONS PAGE FOR CONFIRMATION OF RETROACTIVE DATE)

Limits currently carried

Required

Deductible

Required

Premium

Required

Please provide the following based on the last 12 months of operation. If new agency, provide next 12 months projection.

Agency P & C premium volume

Required

Agency P & C commission income

Required

Agency Life/A & H premium volume

Required

Agency Life/A & H commission income

Required

Consulting/Broker Fees

Required

Mutual Funds and/or Variable Products

Required

Securities

Required

Indicate below the number of staff in your agency as follows (include owners, principals, partners, etc)

Total Licensed

Required

Of the total, how many are: P&C

Required

Of the total, how many are: L&H

Required

Total Unlicensed (with client contact)

Required

Total Contracted Non-Employee Producers

Required

Of the total, how many are: P&C

Required

Of the total, how many are: L&H

Required

(NOTE: PRODUCERS WITHOUT WRITTEN CONTRACTS ARE NOT COVERED.)

Total Staff Series 6 & 7 Licensed

Required

Average years experience Series 6 & 7

Required

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

Required

Yes
No

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

Optional

0
1
2
3 or more

Total Amount Paid

Required

Does the Applicant have any knowledge of any potential errors or omissions claim(s)?

Required

Yes
No

Has the Applicant ever had E&O coverage declined, cancelled or refused renewal? (Not applicable in MO)

Required

Yes
No

(If yes to any of the above, please provide details by attachment to this application)

During the past 5 years, has the Applicant made an "adjustment" or "goodwill payment" in settlement of any dispute?

Required

Yes
No

(If yes, attach explanation concerning payments of $500.00 or more, exclusive of company draft authority.)

Have any employees attended an E&O loss prevention seminar or other industry related education courses within the past twelve months?

Required

Yes
No

(Firm may qualify for loss prevention credit. Please attach documentation of course completion.)

Percentage of business placed with Admitted carriers rated below B+, Non-Admitted carriers rated below A- by A.M. Best OR carriers that are not rated by A. M. Best

Required

Percentage of policies that are Direct Bill

Required

Percentage of policies that Insured Can Make Changes Through Carrier Service Center

Required

Percentage of business placed through any State Administered Work Comp Funds

Required

Are you a

Required

Retail Agent
Wholesaler
Surplus Lines Broker
MGA

Percentage of business placed direct with carriers

Required

Percentage of business placed through a Wholesaler or MGA

Required

Percentage of business placed with carriers that are admitted

Required

Percentage of business placed with carriers that are non-admitted

Required

How many wholesalers are you contracted to write business through?

Required

List top 5 insurance carriers business is placed with and the revenues (your commission) derived from placement

Insurance Carrier

Required

Revenues

Required

Insurance Carrier

Required

Revenues

Required

Insurance Carrier

Required

Revenues

Required

Insurance Carrier

Required

Revenues

Required

Percentage of commission income derived from personal lines

Required

Percentage of commission income derived from commercial lines

Required

Percentage of commission income derived from life & health

Required

Please indicate the percentage of the commission derived from each line of business listed below

THE TOTAL OF ALL LINES OF BUSINESS LISTED MUST EQUAL 100% AND MUST CORRESPOND TO THE PERCENTAGES SHOWN IN PREVIOUS QUESTION

PERSONAL LINES

Auto (Standard)

Required

Auto (Non-standard)/Motorcycles

Required

Homeowners

Required

Non-Standard Property

Required

Pleasure Boats/Craft

Required

Umbrella

Required

Other

Optional

LIFE, ACCIDENT & HEALTH

Individual Life

Required

Group Life

Required

Individual Accident & Health

Required

Group Accident & Health

Required

Fixed Annuities

Required

Variable Annuities

Required

Mutual Funds

Required

Securities

Required

Other

Optional

COMMERCIAL LINES

Property (Standard)

Required

Property (Non-standard)

Required

SMP/BOP/Package

Required

General Liability

Required

Umbrella/Excess

Required

Auto (Standard)

Required

Auto (Nonstandard)

Required

Long Haul Trucking

Required

Workers Compensation

Required

Livestock

Required

Crop

Required

Medical Malpractice

Required

Professional Liability

Required

Inland Marine

Required

Wet Marine

Required

Bonds – Surety

Required

Bonds – All Other

Required

Aviation

Required

Other

Optional

Is there any coverage placed, or involvement with or responsibility as an administrator for self-insured trusts, captives or risk retention groups, risk purchasing groups?

Required

Yes
No

(If yes, please provide details by attachment to this application.)

Is there any coverage placed, or involvement with or responsibility as an administrator for PEO’s, Multiple Employer Trusts (MET) or Multiple Employer Welfare Arrangements (MEWA)?

Required

Yes
No

(If yes, please provide details by attachment to this application.)

Office Procedures (Loss Control credits may be available in this area.)

Is proof of errors & omissions liability insurance required from agents/brokers and/or sub-agents/brokers that place business with your agency?

Required

Yes
No
N/A

Is there an in-house policy/procedures manual in use?

Required

Yes
No

Is there a procedure for documenting phone conversations?

Required

Yes
No

Is all incoming mail date stamped?

Required

Yes
No

Are there procedures that preserve the confidential nature of client’s information?

Required

Yes
No

Is there an in-house training program for new employees?

Required

Yes
No
N/A

Is there a procedure or checklist used in reviewing client coverage/limit requirements?

Required

Yes
No

Are written or electronic records maintained outlining details of all critical conversations, including verbal instructions and oral agreements?

Required

Yes
No

Does the applicant document client’s acceptance and rejection of offers, coverage, conditions and limitations?

Required

Yes
No

Are policies/endorsements checked against the application and other client requests for coverage prior to delivery to clients?

Required

Yes
No

Are umbrella/excess policies reviewed to be certain they are consistent with primary policy terms and conditions?

Required

Yes
No
N/A

Are expirations lists maintained?

Required

Yes
No

If you have answered “No” to any of the questions in "Office Procedures" above, please explain

Optional

Desired Limits of Liability (each claim/aggregate limit applies)

Optional

$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$4,000,000
Other

If Other

Optional

Desired Deductible (each claim/aggregate deductible applies)

Optional

$2,500/$7,500
$5,000/$15,000
$7,500/$15,000
Other

If Other

Optional

It is agreed that if any applicant or director, officer, manager, member, partner, employee or agent of the applicant for whom coverage is being applied for has knowledge of any information concerning any such fact, circumstance, situation, act, error or omissions, whether or not identified in response to Question 15 or 16, any claims arising therefore is hereby excluded from coverage under the policy, if issued. It is hereby agreed that the information provided above is true and correct, and is material in deciding whether to issue the above coverage to the Applicant.

MUST BE SIGNED AND DATED BY OWNER, PARTNER OR SENIOR OFFICER OF THE AGENCY APPLYING FOR COVERAGE

Name

Required

Title

Required

Date

Required

/

/

Upload File

Optional

Upload File

Optional

Upload File

Optional

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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