This form is designed for those agencies wishing to get a quote for Errors & Omissions coverage for their agency, but would like us to market that risk to multiple carriers in order to find the best rate available.

The questionnaire is in 3 parts, each with just a few questions.   To get a quote, click on "Start" below, or call our office at (615) 771-1177.
Start
 
AGENCY PROFILE
(Page 1 of 3)

Tell us about the basic contact information for your agency.
 
Name of Your Agency *

 
Contact Name

 
Position / Title *

 
Primary Phone Number: *

 
Primary Phone Extension

 
What is your website?

 
Address (Street) *

 
City *

 
Zip *

 
County *

 
How did you learn about us? *


 
ABOUT YOUR AGENCY AND BOOK
(Page 2 of 3)

Help us understand more about your agency's staff and book of business.
 
Are you a member of PIA? *

     
 
How many years has your agency been in business under the current ownership? *

 
Is 50% or more of your premium volume crop insurance? *

     
 
Is more than 25% of your business surety bonds, long haul trucking, aviation, wet marine or professional liability? *

     
 
Have you had any E&O claims/incidents in the last three years ? *

     
 
Give a brief description of the claim(s), including approximate date(s) and amount(s) paid.

 
When there is a claim in the past 3 years, most carriers require a copy of loss runs.   If you have those available, please attach them now.   Otherwise, please reply to the confirmation email you will receive later with a copy.   Thank you!   This will help us get you the best possible rate.

 
What is the percentage of total agency commissions, by line of business?

 
Personal Lines % *

 
Please indicate which of the following lines of commissions-based business represents 5% or more of your total agency commissions.(You must make at least one selection):


 
Commercial Lines % *

 
Please indicate which of the following lines of commissions-based business represents 5% or more of your total agency commissions.(You must make at least one selection):


 
Life and Health %

 
Please indicate which of the following lines of commissions-based business represents 5% or more of your total agency commissions.(You must make at least one selection):


 
What is your total annual property and casualty premium volume? *

 
Commission Income (New & Renewal) ($) for P&C?

 
Commission Income (New & Renewal) ($) for L&H?

 
Commission Income (New & Renewal) ($) for Consulting Fees?

 
Do you have multiple locations? *

     
 
What is the address of the second location?

 
Do you have any other locations?

     
 
What is the address of the 3rd location?

 
Do you have any other locations?

     
 
Please list ALL additional locations below

 
What is your staff count for all locations?

 
Staff working more than 20 hours *

 
Staff working 20 hours or less  (If none, enter "0") *

 
Please provide the percentage of your agency's property and casualty premium volume placed:

 
Directly with carriers (as an agent or a broker) *

 
Through any other third party (e.g., a wholesaler, surplus lines broker, MGA or other retail agent)

 
As a broker (business placed on behalf of other entities)

 
As an MGA or Program Administrator

 
Please provide the percentage of your agency's property and casualty premium volume that is received or assumed from the following:

 
Direct from insureds *

 
From other agents/agencies

 
Does 60% or more of your staff, including owners, have an insurance designation (CIC, CPCU, AAI, CISRF, LUTCF, CPIA)? *

     
 
YOUR CURRENT COVERAGES
(Page 3 of 3)

Tell us about your current plan and any changes you would like in your future coverage.
 
Current E&O Limits and Deductibles

 
Current deductible type *


 
Retroactive date *


 
Specified Retroactive Date (Backdate for which you want continuous coverage) *

 
Expiration date of current policy *

 
What is the name of your current E&O carrier? *


 
Some of our carriers require a copy of the current Declaration Page in order to release a quote or indication. If you have those available, please attach it now.   Otherwise, please reply to the confirmation email you will receive later with a copy.   Thank you!   While this is not required, it will help us get you the best possible rate.

 
What is your current expiring policy premium? (Whole dollars, no commas) *

 
Would you like your new policy to have the same limits of liability, deductible, and provisions as outlined above?

     
 
Please describe below what changes you would like on your new policy.

 
ADDITIONAL INFORMATION

Here are some additional questions which may help us secure discounts or better pricing for your coverage.   While they are not required, they could help dramatically reduce your premium.
 
Are you an Independent agent/agency?

     
 
List of Associations of which you are a member


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

     
 
E&O Prevention Seminar last attended?

Thank you for submitting your Easy Estimate information. We are referring this to a specialist at PIA Advantage Services Corp, your exclusive Agent Customer, who will be contacting you shortly to review your request and to obtain further information from you.  You may visit their website by going to: http://www.piatn.com/

Or, if you have questions, please call them at (615) 771-1177.

If you need to send us copies of your current Declaration Page or loss runs, please send them to AdvantageServices@PIATN.com
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