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E&O Easy Estimate Questionnaire - moagent

E&O Easy Estimate Questionnaire - moagent 2026

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The document is an E&O Easy Estimate Questionnaire designed for insurance agencies to provide information necessary for a premium indication. It collects details about the agency's ownership, commission structure, staff count, premium volume, and E&O claims history. The questionnaire emphasizes that it is not a binding offer of coverage and outlines the process for submitting further applications to Utica Mutual Insurance Company.

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Click ‘Get Form’ to open the E&O Easy Estimate Questionnaire in the editor.
Begin by filling in the 'Named Insured' and 'Physical Address' fields. If your mailing address differs, provide that information as well.
Complete the 'Contact Name', 'Phone', and 'E-mail' sections to ensure proper communication.
Indicate whether you are an Independent Agent or Agency by selecting 'Yes' or 'No'.
Fill out the percentage of total agency commission placed by line for PL’s, CL’s, and L&H. Ensure accuracy as this impacts your premium indication.
If applicable, specify the percentage of your income from Specialty Lines and complete the staff count section for both full-time and part-time employees.
Provide details on your current E&O carrier, including limits, deductibles, and any claims/incidents in the last three years.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (217 Votes)

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