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PIA E&O Questionnaire

Please complete the form below to request an E&O indication form from PIA. A PIA E&O producer will be in touch with you to assist you in getting a preliminary quotation on an E&O policy through one of PIA's markets. To contact your local PIA E&O producer, please visit PIA at www.pianet.com/eando.

1) General Information
I) Date Agency Established
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J) E&O Expiration Date
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2) Please provide data for the past 12 months (estimate 12 months of business if new firm):
3) Have you, during the past 12 months, placed business acting as a wholesaler (business placed on behalf of other agents/brokers) or as an MGA/MGU/PA?
4) Please provide premium volume and commission income for the last 12 months in the following areas of placement:
A) Commercial: Automobile – Standard
B) Commercial: Automobile – Nonstandard
C) Commercial: SMP/BOP
D) Commercial: CGL
E) Commercial: Umbrella/Excess
F) Commercial: Workers Comp.
G) Commercial: Long Haul Trucking
H) Commercial: Ocean/Wet Marine
I) Commercial: Bonds
J) Commercial: Aviation
K) Commercial: Medical Malpractice
L) Commercial: Prof. Liability (E&O/D&O)
M) Commercial: Energy/Pollution/Environmental
N) Commercial: Liquor Liability
O) Commercial: Farm Owners & Livestock Mortality
P) Commercial: Crop/Hall (Crop Supp. Required)
Q) Commercial: Other (Specify)
R) Personal Automobile – Standard
S) Personal: Automobile – Nonstandard
T) Personal: Homeowners
U) Personal: Flood
V) Personal: Umbrella
W) Personal: Pleasure Boats
X) Personal: Other (Specify)
8) During the past 5 years, has the applicant, any other predecessor in business, past or present owner, director, officer, partner, principal, employee or contractor:
A) Been the subject of a complaint filed and/or disciplinary action by any insurance regulatory authority?
B) Had any claim(s) made or suit(s) brought against them?
C) Become aware of any fact, circumstance or situation which may result in a claim being made?
10) Does the applicant use "power of attorney" to represent the insured?
11) Does the applicant offer purchasers of automobile policies (i.e. personal auto and commercial vehicles) the option of increasing Uninsured Motorists limits?
A) If yes, are the procedures in place to document this communication?

Disclaimer: While PIA will make a goodwill effort in attempting to contact everyone who submits this form, PIA assumes no responsibility for not notifying individuals who have submitted this form. It is up to the form submitter to monitor and track policy expiration dates and take appropriate measures to ensure continued coverage.

PIA assumes no responsibility for missed expiration dates, undelivered forms due to website errors, or information entered or transmitted that prevents a submitter from being contacted. By clicking the Submit button above, you acknowledge that you understand these disclaimers and will not attempt to hold PIA responsible for any failure to contact you.