Insurance Agents & Brokers
Errors and Omissions

Contact: Dan Hoag at 1-800-735-3455

We have markets for agents/brokers, wholesalers, GA's, MGA's, TPA's and specialists of any kind.

ACCESS TO OVER 20 MARKETS

New Coverage Highlights:

• First dollar defense
• Claims expense outside the limits
• Aggregate deductibles
• Employment practices liability

LIMITS UP TO 20 MILLION
DEDUCTIBLES STARTING AT $1000

You can mail or fax us a copy of your most recent application or complete the indication form below.

* Company Name:
Address:
City:	State:
Zip/Postal Code:
* First Name:
* Last Name:
* Phone:
FAX:
* Email Address:
Insurance Information
Current Carrier:
Limits:
Expiration Date:
Deductible:
Prior Acts Date(s):
Total Volume:
Type of Agency:
Wholesale
Retail
Other
Percentages of Business Classes	(ie; personal or commercial and class.)



Claims	List date of claim amount paid or reserved. If none, state so.
	Date: Amount Paid:
	Date: Amount Paid:
	Date: Amount Paid:

	If you have any other comments or questions, please use the textbox below.
Comments:

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Insurance Information