Errors & Ommissions Quick Quote Form Tell us a little bit about your agency and we will provide you with an E&O Insurance Estimate! Your Agency Named Insured* Address* Street Address Mailing Address (if different) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website* Contact Name* First Last Phone*Email* Are you an Independent Agent/Agency?* Yes No Date Established by Current Ownership* MM slash DD slash YYYY Associations you are a member of PIA of Wisconsin WI Big I Others? Your Book of Business Personal Lines Commission by PercentCommercial Lines Commission by PercentLife & Health Commissions by PercentTotal Commissions (Must equal 100%)Non-Standard or Assigned Risk PL Commissions by PercentNon-Standard or Assigned Risk CL Commissions by PercentWhat percent of your P&C Business is placed through other Agents or Brokers?Total P&C Premium Volume (new and renewal)Do You Write Specialty Lines?* Yes No *Certain Specialty Lines of business may alter the premium and is subject to underwritingWhat percent of your income is placed as Specialty Lines? Your Staff Full Time Staff (over 20-hours)**IMPORTANT - Include ALL the following: Active Agency Principals / Licensed & Unlicensed Personnel / 1099'sPart Time Staff (20-hours or less)**IMPORTANT - Include ALL the following: Active Agency Principals / Licensed & Unlicensed Personnel / 1099's Your Exposure Is an Exposure Analysis Checklist used on ALL accounts (PL and CL – active at least 1 year)?* Yes No Do the Insurance Designations* of staff equals or exceed 60% (CIC, CISR, CPCU, LUTCF, etc)?* Yes No *Does not include having a license.Date of E&O Loss Prevention Seminar last attended MM slash DD slash YYYY Number of staff that attended most recent E&O Loss Prevention SeminarNumber of E&O Claims in the past 3-years?(include closed with expense only payment) Your Current E&O Policy Current E&O Carrier E&O Expiration Date MM slash DD slash YYYY E&O Retro-Active Date MM slash DD slash YYYY Current E&O Limits per ClaimCurrent E&O Limits in AggregateCurrent E&O Deductible per ClaimCurrent E&O Deductible in AggregateCurrent E&O PremiumE&O Type Loss Only Loss & Expense This Questionnaire is for a PREMIUM INDICATION ONLY and is NOT an Offer of Coverage NOR is it BINDABLE. If the premium indication is acceptable, you will be asked to complete a UTICA APPLICATION to submit to Underwriting for further consideration.