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Utica National E&O Easy Estimate

Please completely fill out the questionnaire for the best consideration.

This questionnaire is for premium indication only and is NOT an offer of coverage NOR is it bindable. If premium indication is acceptable, you will be forwarded to underwriting for further consideration.

If you have any questions, please contact Ronnie Roy @ ronnieroy@aiins.us (910-366-4504) or Lisa Farnham @ lisaf@pianc.net (804-486-4222).

Name Insured *

Physical Address *

City *

State *

ZIP / Postal Code *

Website

First Name *

Last Name *

Position

Phone Number *

E-Mail Address *

Are you currently a contracted Utica National P&C agent? *

Associations you are a member of

Date established with current ownership *

Is 50% or more of your premium volume crop insurance? *

If yes, provide %

Is more than 25% of your business surety bonds, long haul trucking, aviation, wet marine or professional liability? *

If yes, provide %

Have you had any E&O claims/incidents over $500 in the last three years? *

If yes, how many:

Percentage of total agency commissions by line:

Personal Lines % *

Commercial Lines % *

Life & Health % *

Percentage of non-standard / assigned risk placed by line:

Personal Lines % *

Commercial Lines % *

Total annual (new & renewal) property & casualty premium volume: $ *

Staff count (include owners and principals):

Full-time (over 20 hours) # *

Part-time (20 hours or less) # *

Percentage of your agency's property & casualty premium volume placed:

Direct with carriers (as agent/broker) % *

Through any other 3rd party (e.g., wholesaler, surplus lines broker, MGA, or other retail agent) % *

As a broker (business placed on behalf of other entities) % *

As an MGA or Program Administrator % *

Percentage of your agency's property & casualty premium volume that is received or assumed from the following:

Direct from insureds % *

From other agents % *

Does 60% or more of your staff, including owners, have an insurance designation (CIC, CPCU, AAI, CISRF, LUTCF, CPIA)? *

Current E&O carrier *

Expiration Date *

Retroactive date: *

Current Premium $ *

Limits

Per Claim $ *

Aggregate $ *

Deductible

Per Claim $ *

Aggregate $ *

Type of Loss

Loss Only
Loss & Expenses

Please attach your current E&O

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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