E&O Intake Form
Referred by
*
Policy Effective Date
*
-
Month
-
Day
Year
Date
State Insurance License Issued
*
-
Month
-
Day
Year
Date
Business Name
*
DBA or Operating Name :
Business Ownership Structure
*
Please Select
Corporation or other Organization (other than the above)
Individual / Sole Proprietor
Joint Venture
Limited Liability Company
Partnership
Trust
Business Owner's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mailing Address
*
Insured's email address
*
example@example.com
Insured's phone number
*
Please enter a valid phone number.
Number of additional locations
*
0
1
2
3
4
5+
What is the business's estimated gross sales during the next 12 months?
*
Life, Accident or Health
*
Yes
No
Commercial lines
*
Yes
No
Does the business perform an annual account review with each of its clients?
*
Always
Sometimes
Never
Does the business provide insurance placement or advice for any of the following insurance products or services? Aviation insurance, Lawyer’s liability insurance, Mining insurance, Multiple Employer Welfare Arrangements (MEWA), Variable annuities, mutual funds, stocks, or investment bonds, Variable life insurance
*
Yes
No
Does the business provide services in the capacity of the following? Managing General Agent (MGA), Managing General Underwriter (MGU), Professional Employer Organization (PEO), Program administrator or Third Party Administrator (TPA), Reinsurance intermediary, Risk Retention Group (RRG), Wholesale broker, Health Maintenance Organization (HMO) plan creator, manager and/or administrator
*
Yes
No
Does the business provide any of the following services? Actuarial advice, Financing or financial auditing, Investment or tax advice, Legal advice, Lobbying and/or political advice, Medical advice, Mergers and acquisitions or business valuations
*
Yes
No
Does the business currently have an insurance policy in effect for the coverage requested?
*
Yes
No
Prefer not to answer
If Yes, provide the name of your insurance carrier.
Do you have the retroactive date of the business's current Professional Liability policy?
Approximately when did the business begin?
*
-
Month
-
Day
Year
Date
Classification of Business
If required by state law, does the principal of the firm maintain current and valid professional training, certifications, licenses or designations for all services provided?
*
Yes
No
Not required
Submit
Should be Empty: