Broker Evaluation Intake Form

Entity Name

Entity Website

Contact First & Last Name

Contact Email Address

Contact Phone Number

Phone

Total volume and mix of business currently with Hiscox?

Where are you domiciled (city/state)?

In which states are you licensed for P&C?

(Select al that apply)

Do you have more than one office/location?

Yes

Please list your office location(s) below

Do you have a marketing department & dedicated field reps?

Yes

What is your current marketing mix? Email, social media, direct mail, incentives, other?

How many active independent agents do you serve?

What is the current total value of your book of business?

Please list any online, digital, quote and bind platforms you currently use

What are your top 3 markets?

Please list all small business carriers you currently work with

Do you specialize in any specific LOB’s / COB’s, or are you more of a Generalist?

Do you use other carriers for similar/same classes? If so, how would you see the re-allocation of some of that business moving to Hiscox NOW?

Is there any known current or pending litigation against your company?

(If yes, please provide details below)

Has your Company or any partners, officers, owners, or producers of the company ever been subject to any Department of Insurance action regarding a violation?

(If yes, please provide details below)

Have there been any Errors & Omissions (E&O) claims made against your agency, partners, officers, owners, or producers in the past five (5) years?

(If yes, please provide details below)

Are there currently any open liens levied against your agency and/or partners, officers, or owners?

(If yes, please provide details below)

Please provide the following as part of our evaluation

1. Please attach licensing documents

Drop your files here

Additional Information

*Goal Commitment: Your Business Development Manager will set your goal commitment, if approved. Modify the existing link in this field to the broker appetite guide link: What Hiscox products are offered through brokers? What Hiscox products are offered through brokers? | Hiscox

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