Membership

Errors & Omissions Carriers

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Information Request

Errors & Omissions Submission

* denotes required field

Your Information

*First Name :**
*Last Name :**
Company:
Address:
City:
State:
Zip:
Phone:
Fax:
*Email :**
PIA Member:	Yes No
Please send information regarding membership

Current Carrier

Current Carrier:
Limits:
Deductible:
Expiring Premium:
Expiration Date:
Retro Date:

Last 12 months of Operation

Agency P & C premium volume:
Agency P & C commission income:
Agency Life/A & H commission income:
Fee income from other Agency activities:
List type of other activities:
Staff Size :
Number of Owners, Officers :
Number of Employees:
Number of Exclusive Independent Contractors:
Total:

Business Placed As

All fields should be in percentage (%) format.

Agent:
Broker:
Surplus Lines:
MGA:

Specialty Lines

All fields should be in percentage (%) format.

Non-standard Auto:
Ocean Marine:
Aviation:
Bonds:
Professional Liability:
Long Haul Trucking:
Oil & Gas:
Pollution:
Percentage of Personal Lines:
Percentage of Commercial Lines:
Percentage of Company Direct Bill:
Have you or any of your staff taken an Agent's E&O course during the past 2 years?: Yes No:
Mutual Funds Revenue:
Real Estate Revenue:

Top Carriers

Please list your top carriers equal to 85% of your volume.

	Carrier	Volume
1:
2:
3:
4:
5:

Miscellaneous

What percentage of your total volume is placed with Non-Admitted carriers? (%)
Have you had any claims or circumstances in the last five (5) years:	Yes No:
If you answered yes to the above question, please detail all claims information within the last five (5) years, include date/reserves/amount paid/ open or closed: