E&O Request Form (2024 Now Available)
Coverage only applicable to policies/enrollments through Trusted Senior Specialists.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
The group E&O Coverage offered is only valid for business written through Trusted Senior Specialists. If you are contracted with additional carriers outside of Trusted Senior Specialists, you may still be required to purchase an individual policy and should refer to each specific carrier to confirm you meet all of their requirements. Do you understand and agree?
*
YES
NO
Upon submission, you will receive instructions on how to generate your E&O Certificate. The instructions may not be shared with anyone else. Each agent MUST submit their own request for coverage through our E&O Request Form. Do you understand and agree?
*
YES
NO
The E&O Policy expires each year on June 30th. Renewal is NOT automatic. If you want to continue coverage, you are responsible for notifying us. Failure to do so, will result in coverage ending. Do you understand and agree?
*
YES
NO
By signing below, you acknowledge that you understand and agree to all of the above. You further agree that you will NOT share the instructions on how to generate a certificate with anyone. You may share the link to the E&O Request Form with any agent who is contracted with Trusted Senior Specialists so that they can request their own coverage. To continue, please use your mouse to provide you signature and then click the Submit button.
*
Clear
Submit
Should be Empty: