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Broker Questionnaire
First Name
(required)
Last Name
(required)
Company Name
(required)
Street Address
(required)
City
(required)
State
(required)
Postal Code
(required)
Phone Number
(required)
Email
(required)
Company Type
(required)
Corporation
Partnership
Individual
Taxpayer ID Number
(required)
Year Business was Established
(required)
Are you a member of any Agency Association?
(required)
Yes
No
If yes, please list the Associations
Number of Years Experience with Lawyers Professional Liability
(required)
Premium Volume of Book
(required)
Are you a Wholesaler?
(required)
Yes
No
Principles/Partners/Owners
Break down the number of staff
Officers/Managers
Break down the number of staff
Licensed Producers
Break down the number of staff
Other Employees
Break down the number of staff
Total Staff
(required)
Do you maintain Errors & Omissions Coverage?
(required)
Yes
No
Insurance Company
Limits
Deductible
Expiration Date
MM slash DD slash YYYY
Has any member of your firm received any disciplinary action by a state insurance department or other regulatory authority?
(required)
Yes
No
If yes, please explain:
Phone
This field is for validation purposes and should be left unchanged.
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