Insurance Agents Professional Liability Quote

Agency Name:
Agency State:
Phone Number:
E-mail Address:
Contact Name:
Effective Date (MM/DD/YYYY):
Describe professional services and percentage of revenue from each activity (must total 100%):
Personal Lines Auto %
Personal Homeowner %
Commercial Lines %
Life and Health %
Estimated Annual Commission:
Number of Employees:
Is E&O insurance currently in force?
If Yes, provide information regarding coverage during the past twelve months:
During the last five years, have there been any professional liability claims against the Applicant?
Has any insurer cancelled, rescinded, non-renewed or declined in the last five years?
Limits of Liability:
Deductible: