E & O Quick Quote Form - Utica National Insurance Group

Welcome to Utica National Insurance’s unique E & O Program, designed specifically to meet the needs of the Independent Agent.

Getting a premium indication from Utica National couldn't be easier. If you meet the qualifications below, please continue on to our Quick Quote form.

Our program is designed for the Independent Agent who:

has been licensed for 2 or more years
is not an MGA
is not acting as a Reinsurance Intermediary

Should more than 50% of your services include surety bonds, long haul trucking or aviation, please click here to ask our local representatives to call you about other opportunities.

Our thanks to the many Independent Agents who have helped make our program such a success!

We have a special program for agents when more than 50% of your volume is in the Life, Accident and Health field. Please click here for the application.

It takes just a couple of minutes of your time to obtain a solid premium indication for your Agency's Errors & Omissions Coverage. You will receive a call from Professional Insurance Agents of North Carolina within 48 business hours with a premium indication from the experts.

(Note: All fields are required to obtain a proper premium indication. This information will be used to predict a premium only, and is not an offer of a bind-able proposal.)

AGENCY INFORMATION
Agency Name:
Street Address:
City:
State:
Zip Code:
Federal ID #:
Contact Name:
Phone:
E-Mail:
Date Agency Established:
If under 3 years - Describe Experience:
Are you a member of PIA or PIA/IIA Merged?
Staff Size: (Includes all agency principals, producers, support staff, 1099's, licensed, and unlicensed employees, etc.)	Full Time (over 20 hours per week)
	Part Time

INCOME
Property / Casualty Premium Volume:	$Commissions:$
Life / Health Commissions:	$Consulting Fees:$

BUSINESS PLACED

Your Personal Lines, Commercial Lines, and Life/Health business percentages placed must add up to 100%

Personal Lines: %	Commercial Lines: %	Life/Health: %
Standard %	Standard %	Individual Life %
Non Standard %	Non Standard %	Individual Health %
Specialty %	Specialty %	Group Health %

What % of your business is placed through or from other agents/brokers? (incl Surplus Lines)

LOSS CONTROL
Do you have an (active and maintained) Office Procedures Manual?
Exposure Analysis Checklist on ALL PL & CL accounts?
Does 60% of your staff have insurance designations (CIC, CISR, CPCU, LUTCF, etc)?
Have you ever attended an E & O Loss Prevention Seminar?
Date of most Recent E & O Loss Prevention Seminar attended:
Number of staff who attended:
Learn more about how our Loss Control Credit Program can save you money!

CLAIMS INFORMATION
How many E & O claims/incidents has your agency had over the last 5 years?

ADDITIONAL COVERAGES DESIRED

CURRENT E & O COVERAGE

Carrier:

Expiration Date: Retro-Active Date:

Full Prior Acts Coverage?

Limits: $ per claim$ aggregateExpiring Premium: $

Deductible: $ per claim$ aggregate