Integra Partner Agents E&O Program

Integra Agent Partners - THANK YOU for the opportunity to earn your business!

The form below will allow us to efficiently gather the information we need to get started on your quote request. In order to complete the form, you will need information such as your business' gross sales and any DBAs your business might have. Remember, you cannot save your progress. So, if you do not have this info handy, please gather it and come back later.

If you prefer to speak with one of our commercial insurance specialists, please call: (210) 708-3203

Integra Agent Partners EO App

Step 1 of 7

14%

Coverage Eligibility

Has the Applicant done ANY of the following within the last 6 years?(Required)

Placed coverage or been involved in any Reinsurance business;

Performed any activities as a Managing General Agent/Program Administrator, or in any similar capacity, for an insurance company;

Performed any claims handling or had any claims settlement authority;

Performed third party administrator duties;

Placed any Medical Malpractice, Energy, Aviation, Animal Husbandry, Contingency, Crop, Long‐Haul Trucking, or Personal Accident insurance coverage; and

Performed any Financial Planning activities which in any given year collectively exceeds 10% of the Applicant’s annual revenue for that given year

NONE OF THE ABOVE

Did you answer ‘Yes’ solely because you place or have placed any Medical Malpractice, Energy, Aviation, Animal Husbandry, Contingency. Crop, Long‐Haul Trucking, or Personal Accident insurance coverage?(Required)

Yes

Did you place these coverages through a wholesaler who specializes in these placements?(Required)

Yes

Please select ALL of the following procedures you implement in your office:(Required)

Has and/or provides checklists and written protocols to staff as to what is required for placement/renewal of coverage;

Requires that all communication be documented, written instructions obtained, and that the documentation be preserved;

Uses a diary/calendar system to keep track of deadlines and/or significant dates in order to timely follow up with clients;

Has procedures in place for verification of payees, including telephone verification, and email/wire address comparisons;

Provides or requires additional training to its staff in addition to basic licensing requirements; and

Requires written confirmation from their client if placing business with insurers with an AM Best rating of B+ or less.

Applicant Information

Name of Applicant (include all dba’s):(Required)

Business Physical Address:(Required)

Street Address City State ZIP Code

Is your mailing address the same?(Required)

Yes

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Contact Person's Name:(Required)

First Last

Contact Email:(Required)

Contact Phone:(Required)

Agency's Website:(Required)

Date your agency was established:(Required)

Estimated gross revenue for the current 12 months:(Required)

Previous Insurance Information

Do you currently have professional liability insurance in force?(Required)

Yes

Name of Current E&O Provider:(Required)

Current Limits on policy:(Required)

Retroactive date listed on policy:(Required)

MM slash DD slash YYYY

The Applicant warrants that the requested Retroactive Date is the date in which the applicant has been continuously insured without interruption. The actual Retroactive Date will always be the first date of continuous and uninterrupted coverage. If the Applicant does not have coverage currently in force, the retroactive date will coincide with the inception date of any policy approved and issued.

Please upload a copy of your current declaration page showing the retroactive date of your policy.

Drop files here or

Max. file size: 5 MB.

If not available at this time, you can email in to commercial@myinsurancegroup.com at a later time.

Do you currently have a Cyber Liability insurance policy in force?(Required)

Yes

Cancellation

Have you had any agency contracts cancelled by an insurance carrier for reasons OTHER THAN lack of production?(Required)

Yes