E&O INFORMATION REQUEST FORM

Please complete the entire form and click submit. A BIGiOK E&O representative will contact you within 2 business days. Thank you.

Agency Name

Is your agency a BIGiOK member?

First Name

Last name

Work phone

Phone

Address

City

State

Zip

Year agency was established

Has the agency principal(s) been licensed more than 3 years?

Premium volume past 12 months / projected premium volume:

P&C commission past 12 months / projected commission income

Life, A&H commission past 12 months / projected commission income

Percentage of business placed:

% Commercial Lines

% Personal Lines

% Life & Health

Policy effective date

mm/dd/yyyy

Agency staff size

Current limits carried

Deductible

Premium

Who is your current E&O carrier?

Have you had any claims in the past 5 years?

Any specific coverage needs or concerns you'd like addressed?

Send me a copy of my responses