Insurance Questionnaire

General Information

Mailing Address
Independent Agent / Agency?
MM slash DD slash YYYY
Percentage Of Total Agency Commission Placed By Line
Percentage Of Non-Standard Or Assigned Risk Placed By Line
Specialty Lines?
INCLUDE ALL THE FOLLOWING ACTIVE AGENCY PRINCIPALS / LICENSED & UNLICENSED PERSONNEL / 1099'S

Errors & Omissions Coverage

CHECK IF NOT INTERESTED IN RECEIVING A QUOTE FOR THIS COVERAGE.
MM slash DD slash YYYY
MM slash DD slash YYYY
Deductible Type
Insurance Designations (not including license) Of Staff Equals Or Exceed 60% (CIC, CISR, CPCU, LUTCF, etc)?
MM slash DD slash YYYY
* Please note only courses on carrier approved listing will apply towards any applicable filed credit

Agents Umbrella Coverage

CHECK IF NOT INTERESTED IN RECEIVING A QUOTE FOR THIS COVERAGE.
$10 million maximum limit. Higher limits may be available subject to underwriting and reinsurer approval.
MM slash DD slash YYYY
Limit $
Desired Retention Limit
Does Your Current Coverge Include The Agency's E&O?
Check Underlying Coverages Currently In Place
BOP/General Liability
Limit $
MM slash DD slash YYYY

Employer’s Liability
Limit $
MM slash DD slash YYYY

Commercial Auto
Limit $
MM slash DD slash YYYY

Are There Any Operators Of Agency Vehicles Under The Age Of 22?
Agency-Owned Watercraft?
If Yes, Length in Ft.
Horsepower
 
Any E&O, Auto Liability Or General Liability Losee Over $100,000 In Past 5 Years?
EXCESS EMPLOYMENT PRACTICES LIABILITY
If You Have A Minimum Underlying EPLI Limit Of At Least $1,000,000 And Is Not Shared With Any Other Coverages, Are You Interested In Excess Employment Practices Liability?
If Yes, please answer the next two questions:
Excess EPLI Limits Requested
Have You Had Any EPLI Claims In Excess Of $100,000 In The Past 5 Years?
If yes, please attach currently valued loss runs
Drop files here or
Accepted file types: pdf, docx, Max. file size: 200 MB, Max. files: 5.
    PERSONAL UMBRELLA ENDORSEMENT (PXL)
    For Agency Owners, Officers, Or Partners, Are You Interested In Personal Umbrella Endorsement (PXL)?
    If Yes, please complete the following information:
    maximum $5,000,000 subject to acceptable exposures, PXL limit may not exceed the commercial umbrella limit
    Note: Minimum Underlying Limits Required:
    • PAP: $500,000 Ea. Per. BI /$500,000 Ea. Acc. BI/$100,000 PD or $500,000 CSL
    • Per. Liability: $300,000 Each Occ. w/o pool or $500,000 Each Occ. with pool
    • Watercraft Liability: $500,000 for boats < 35 feet, $1,000,000 for boats 36 to 50 feet (over 50 feet, jet skis, wave runners and similar personal watercraft are not eligible for coverage).

    Please attach an Acord 83 Personal Umbrella application for each PXL requested.

    Drop files here or
    Accepted file types: pdf, docx, Max. file size: 200 MB, Max. files: 5.
      EXCESS EMPLOYEE BENEFITS LIABILITY
      If You Have A Minimum Required Primary Limit Of $250,000 Per Employee/$750,000 Aggregate, Are You Interested In Excess Employee Benefits Liability?
      If Yes, please complete the following information:

      Cyber Liability Coverage

      CHECK IF NOT INTERESTED IN RECEIVING A QUOTE FOR THIS COVERAGE
      MM slash DD slash YYYY
      MM slash DD slash YYYY

      Employment Practices Liability Coverage

      CHECK IF NOT INTERESTED IN RECEIVING A QUOTE FOR THIS COVERAGE
      Limit Of Liability Desired
      MM slash DD slash YYYY
      MM slash DD slash YYYY
      Number Of Employees In The Following States
      CA
      FL
      NJ
      NY
      TX
       
      Any Claims, Suits Or Other Demands Over Last 5 Years?
      If yes, provide a list of all claims, suits or other demands for wages, reinstatement or other relief against the Applicant in the past five years (include closed with expense only payment)?
      Drop files here or
      Accepted file types: pdf, docx, Max. file size: 200 MB, Max. files: 5.

        Additional Coverage

        CHECK IF NOT INTERESTED IN RECEIVING A QUOTE FOR THIS COVERAGE

        Sign, Date, and Submit

        If you have questions about the form or submission, please contact IA&B Insurance Specialist David Wertz at DavidW@IABforME.com or 800-998-9644, ext. 506 or Insurance Agency Sr. Director Kevin Hord at KevinH@IABforME.com or 800-998-9644, ext. 209. Please note that IA&B core hours of operation are Mon-Fri, 8:30AM - 4:30PM.

        This questionnaire is for a Premium Indication ONLY. It’s not an Offer of Coverage or bindable. If the premium indication is accepted, a full application is needed.
        MM slash DD slash YYYY
        This field is for validation purposes and should be left unchanged.
        650 Wilson Lane, Suite 200
        Mechanicsburg, PA 17055
        191 Main Street
        Annapolis, MD 21401
        Toll Free: 800-998-9644
        Fax: 717-795-8347
        Email: IAB@IABforME.com
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