Errors & Omissions Quick Quote Form

Named Insured *

Address Line 1 *

Address Line 2

City *

State *

Enter required value

Postal Code *

Website *

First Name *

Of Contact

Last Name *

Phone *

Email *

Are you an Independent Agent/Agency? *

Enter required value Yes No

Date Established by Current Ownership: *

Associations You Are a Member Of:

PIA of Wisconsin

WI Big I

Other

Personal Lines Commission by Percent

Commercial Lines Commission by Percent

Life & Health Commission by Percent

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 & Renewal)

Do You Write Specialty Lines? *

*Certain Specialty Lines of business may alter the premium and is subject to underwriting

Enter required value Yes No

Full-Time Employees *

(Over 20 Hours)

*IMPORTANT - Include ALL the following: Active Agency Principals / Licensed & Unlicensed Personnel / 1099's

Part-Time Employees *

(20 Hours or Less)

*IMPORTANT - Include ALL the following: Active Agency Principals / Licensed & Unlicensed Personnel / 1099's

Is an Exposure Analysis Checklist used on ALL accounts (PL and CL - active at least 1 year)? *

Enter required value Yes No

Do the Insurance Designations* of staff equal or exceed 60% (CIC, CISR, CPCU, LUTCF, etc.)? *

*Does not include having a license.

Enter required value Yes No

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)

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