REACH E&O Intake Form

E&O Intake Form
Referred by
Policy Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Insurance License Issued

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Business Name
DBA or Operating Name :
Business Ownership Structure
Business Owner's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address - Include City, State and Zip Code
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?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?
Should be Empty: