INSURANCE AGENCY - COVERAGE INDICATION REQUEST FORM
 
 
 
 
 
 
Section 1 - About Your Business
 
 
 
 
Company*
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Phone (xxx) xxx-xxxx*
 
 
Fax (xxx) xxx-xxxx*
 
 
 
Email*
 
 
 
 
Year Established*
 
 
Number of Locations*
 
 
 
Date owner first licensed (mm/dd/yyyy)
 
 
 
 
Gross Annual Revenue*
 
 
Total Premium Volume (approx)*
 
 
 
Personal Lines %*
 
 
Commercial Lines %*
 
 
 
What percentage of your total annual premium is derived from crop sales?*
 
 
 
 
 
 
 
Agent/Broker (P&C) Revenue %*
 
 
Life & Health Revenue %*
 
 
 
Fee-Based Activity Revenue %*
 
 
Describe*
 
 
 
 
 
 
We will be better able to respond with the following information.
 
 
 
 
Section 2 - About Your Current Policy
 
 
 
 
E&O Insurance Carrier
 
 
 
 
Effective Date (mm/dd/yyyy)
 
 
Retro Date (mm/dd/yyyy)
 
 
 
Limits
 
 
Deductible
 
 
 
Premium
 
 
 
 
 
 
 
Section 3 - About Your Experience
 
 
 
 
Has any policy been cancelled or non-renewed?
 
Yes
No
 
 
 
 
 
 
Have you had any E&O claims during the last 5 years?
 
Yes
No