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Producer Questionaire

Name
Title
Name of Firm
Address
City
State
Zip code
Email

Website
Telephone

Fax

 

Check all that describe your organization

Corporation
LLC

 

Partnership
Individual

Principles & Personnel

Breakdown of Producer's Staff

Please provide a number for each: Current Year
Principles/Partners/Owners
Officers/Managers
Brokers (other than above)
Other Employees

Total Staff

 

Operations

Do you write business outside of State of Domicile?
           Yes        No

If yes, please explain:
List ALL Branch Offices:

List States with Licenses:

State License # State License #
                 

Please forward copies of all your current licenses.

Premium Volume

List your volume by category:

Category Current Year Previous Year
D & O      
EPLI
E & O
Other Professional Liability     
Total

List Major Companies/Wholesale Brokers in order of Premium Volume

Name Years represented      Annual Volume
     
     
     
     
     
     
     
     

Production to Company

Anticipated volume to company from following sources:

New Business $
Transfer from current company in office      $
Transfer from discontinued company $

Explain briefly:

 

Name of Accounting Contact at your firm
Bank Reference
Bank Name
Address
City
State
Zip code
Bank Contact
Contact Phone #
 

Do you maintain E & O Coverage?
           Yes        No

If yes, please indicate the the following:

Insurance company
   
$ Limit $ Deductable  

Exp. Date (mm/dd/yy)

 

   

Has any member of your firm received disciplinary action by the state Insurance department or any other regulatory authority?
           Yes        No

If yes, please explain:

Is there any pending or threatening litigation or judgements within the past 5 years exceeding $5000.00?
           Yes        No

If yes, please explain:

How did you hear about Pro-Risk Solutions?

Additional Comments: