INSURANCE AGENCY - COVERAGE INDICATION REQUEST FORM
Section 1 - About Your Business
Company
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
CW Northern Mariana Islands
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Phillippine Islands
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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