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Agents E&O Quick Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly. Email any additional information to INSURANCE@USEO.COM or fax additional information to 713-984-1152. Call 800-460-6424 for any questions.

Basic Information
Agency Name
Required
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Fax
Optional
E-Mail Address
Required
Premium Volume
Last Year (last 12 months, including new and renewal business)
Required
Current Year Estimate
Optional
Commissions
Last Year
Commercial Lines Gross Commission Income
Required
Personal Lines Gross Commission Income
Required
Life & Health Gross Commission Income
Required
Total Number of all owners, licensed agents, 1099 producers and clerical staff (count each person only once)
Required
INDICATE THE PERCENTAGE OF TOTAL COMMISSION INCOME THE AGENCY PLACES IN THE FOLLOWING CLASSES OF BUSINESS:
Medical Malpractice %
Required
Trucking (fleet and long haul) %
Required
Crop %
Required
Life %
Required
Annuities and Pension %
Required
Bonds %
Required
Aviation & Wet Marine & EEP %
Required
Non-Standard Auto (Personal & Commercial) %
Required
Property & Dwelling %
Required
Health and Accidental (Personal & Group) %
Required
Other FLOOD/WINDSTORM/OCC ACCIDENT %
Required
Type of Carrier
% Admitted Direct
Required
% Non-Admitted
Required
% of Business with Non-rated/Demotech rated carriers
Required
Next 12 Year Estimate of Gross Commission Income
Commercial Lines Gross Commission Income
Optional
Personal Lines Gross Commission Income
Optional
Life & Health Gross Commission Income
Optional
Agency Information
Retail Agent
Required

Wholesale/MGA/MGU/Program Administrator
Required

Number of full time employees including active owners
Required
Number of part time employees
Required
Number of independent contractors
Required
Have you had any losses paid or reported in the past five years?
Required

If "Yes" to the question above, please provide claim information below and fax or email your 5 year loss run to us:
Optional
Have you had continuous E&O coverage for the past five years?
Required

During the past year, have there been any mergers, acquisitions, or change in ownership or agency operation?
Required

If "Yes" to the question above, please provide an explanation below:
Optional
Do you write 30% or more of your premium volume through MGA's or other agents (brokered business)?
Required

Percentage of premium volume with a carrier that is not rated B+ or better by A.M. Best or only rated by Demotech ?
Required
Percentage premium volume with a non –admitted carriers
Required
What is the premium you expect to pay this year?
Optional
Expiring Limits
Optional
Expiring Deductible
Optional
Expiration Date
Optional
/ /
How did you hear about us?
Optional
Submission Validation
Required
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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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