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Quick Quote

All fields are required to obtain a proper premium indication- do not leave any fields blank, if needed, please estimate volume or put none or N/A. This information will be used to predict a premium only, and is not an offer of a bind-able proposal.
A full Errors and Omissions Application must be competed and underwritten if coverage is desired. In order to provide a representative Premium indication for your agency, be certain to proved current and accurate information, especially in the staff size, premium volume/commission/revenue areas. Thank you.

Company/Agency Information

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Physical Address

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Mailing Address

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Agent/Agency Information

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Staff Information


You must include ALL agency principals, producers, support staff, 1099’s, licensed and unlicensed employees, etc.
Over 20 hrs per week is counted as Full Time
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Income

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Business Placed


Percentages for each line
Please enter the percentage of your business from each of the insurance lines. The percentages listed below for Personal Lines, Commercial Lines, and Life/Health Lines must add up to 100%
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Personal Lines Detail
The percentages listed below for Standard, Non Standard, and Specialty must add up to 100%
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Commercial Lines Detail
The percentages listed below for Standard, Non Standard, and Specialty must add up to 100%
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Life/Health Lines Detail
The percentages listed below for Individual Life, Individual Health, and Group Health must add up to 100%
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Loss Control

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Claims Information

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Current E&O Coverage

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Submit your Quick Quote Request

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PIA Large

Professional Insurance Agents of Wisconsin
6401 Odana Road | Madison, WI 53719
Phone: (608) 274-8188 | Toll Free (800) 261-7429
Fax: (608) 274-8195 | Toll Free (866) 203-7461

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