E&O Quick Quote Form - PIA of Wisconsin

Your Agency

Named Insured*

Address*

Street Address Mailing Address (if different) City State ZIP Code

Website*

Contact Name*

First Last

Phone*

Email*

Are you an Independent Agent/Agency?*

Yes
No

Date Established by Current Ownership*

Associations you are a member of

PIA of Wisconsin
WI Big I
Others?

Your Book of Business

Personal Lines Commission by Percent

Commercial Lines Commission by Percent

Life & Health Commissions by Percent

Total Commissions (Must equal 100%)

Non-Standard or Assigned Risk PL Commissions by Percent

Non-Standard or Assigned Risk CL Commissions by Percent

What 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 underwriting

What 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's

Part 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

Number of staff that attended most recent E&O Loss Prevention Seminar

Number 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

E&O Retro-Active Date

Current E&O Limits per Claim

Current E&O Limits in Aggregate

Current E&O Deductible per Claim

Current E&O Deductible in Aggregate

Current E&O Premium

E&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.

Errors & Ommissions Quick Quote Form

Your Agency

Your Book of Business

Your Staff

Your Exposure

Your Current E&O Policy