Errors & Omissions Insurance Application (For Distributors)
Please fill out the following form in order to receive a quote for insurance.
APPLICANT INFORMATION
How did you hear about us? *
Select how you found our website.
Applicant / First Named Insured (including DBAs): *
NOTE: First Named Insured is responsible for premium payment, cancellation and changes – refer to specimen policy.
Your answer
Entity Type
Street Address *
USA addresses only. No P.O. Boxes.
Your answer
City *
Your answer
State *
Zipcode
Your answer
Are there other Named Insureds and/or subsidiaries, affiliates, branch offices or other related entity(ies) (including DBAs) for which coverage is desired? *
If yes, please provide a list of entities for which coverage is desired.
Your answer
Are there any entities seeking coverage as an “Additional Insured” arising from their vicarious liability (i.e. distributors, licensees, exhibitors, bond companies, financiers, etc.)? *
If yes, please provide a list of entities for which coverage is desired.
NOTE: These entities may already be covered by the definition of “Additional Insured” within the policy (refer to specimen policy).
Your answer
PRIMARY CONTACT INFORMATION
First Name *
Your answer
Last Name *
Your answer
Email *
Please check your email is entered correctly or you may not receive a response.
Your answer
Phone *
Your answer
Other Phone
Your answer
Website
Your answer
Driver's License Number
(Not required for quote.)
Your answer
Description of business operations: *
Your answer
Federal Tax ID Number *
Policies with workers' compensation included will require the entity's or principle's tax ID number to be given to the broker at the time of purchasing the policy.
Required
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