REACH E&O Intake Form

Referred by

Policy Effective Date

Date

State Insurance License Issued

Date

Business Name

DBA or Operating Name :

Business Ownership Structure

Business Owner's Name

First NameLast Name

Date of Birth

Date

Mailing Address

Insured's email address

example@example.com

Insured's phone number

Please enter a valid phone number.Format: (000) 000-0000.

Number of additional locations

What is the business's estimated gross sales during the next 12 months?

Life, Accident or Health

Commercial lines

Does the business perform an annual account review with each of its clients?

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

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

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

Does the business currently have an insurance policy in effect for the coverage requested?

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?

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?