First Name*
Last Name*
ZIP Code*
1. What is the name of the agency you would like to add?*
2. Are you the sole owner of the corporation/agency/LLC?*
If "no", please explain why
3. Are you the sole producer of the corporation/agency/LLC?*
If "no", please explain why
4. Do you understand that this is an individual policy?**
*This means that as it is an individual insurance agents E&O policy in the case where a business name appears on the certificate, coverage for that business is limited to that business's vicarious liability for the covered wrongful acts of the individual named insured. This policy provides coverage for the individual acts of the named insured. This coverage is not intended to cover claims against the agency for the acts of employed or independent contractor agents.
If "no", please explain why
5. Do you understand that if you hire any producing agents, W-2 or independent contractors, this policy does not cover the agency, or you, for E&O of any other agents at the agency? If you plan to hire agents or sub-agents, we recommend an agency policy?*
If "no", please explain why
Please type "I understand" if you agree and understand the policy terms in regards to the definition of an "insured".*
If you had to answer "no" to any of the above, please explain why.