Answers are required for each question. You should have the group E & O enrollment offer in front of you to answer questions regarding premiums.
If you have had claims, you will be prompted to enter information relating to the total costs and reserves. If you do not know what the reserves are a good faith estimate from the adjustor or attorney is advised.
No answers in relation to projected premium cost can be given on this site as the data you provide will be the determining factor
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| General Information |
1. Your private Non Farmers Email Address
If you have already started or completed this survey, please click here to login and access your data.
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| 2. State of Operation |
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| 3. Date of agency appointment |
(mm/dd/yyyy) |
4. Type of policy you currently have
(If you do not have coverage in place, please indicate the limit you are interested in.)
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Current group policy
Individual policy
No current coverage
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| 5. Select your current limit of coverage |
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
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| 6. Have you opted for coverage for commercial brokered business option? |
Yes |
| 7. Have you purchased the deductible buy back? |
Yes |
| Premium Costs for all Limits of Coverage |
| 8. Please have the group E & O offer in front of you, and enter the cost for each option of coverage available (not just your selected limit). See Example |
| 8a. Limit of Coverage
| 8b. Monthly Cost without outside commercial option
| 8c. Monthly Cost with outside commercial option
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| 1,000,000 |
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| 2,000,000 |
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| 3,000,000 |
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| 4,000,000 |
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| 5,000,000 |
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| Producers and Staff |
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9. Number of licensed agency producers (including agency owner) including clerical and outside sales staff
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10. Number of non licensed agency staff
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| Annual Agency Premium Volume |
| 11. Total agency premium volume this last calendar year (new and renewal combined)
To calculate annual premium volume, estimate your agency annual gross commissions x 10 = Annual Premium Volume
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12. The following percentages must equal 100% of you annual agency premium volume and must include new and renewal business. The first 4 questions are for Farmers production only, the last is for outside business of all types.
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| Claims |
13. How many claims or suits have been made against your agency in the last 5 years? Please include ones that were not reported to the E & O carrier but Farmers agreed to pay your insured's loss even though it was initially denied.
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| Discipline by Regulatory Authorities |
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14. Have you been subject of any discipline by any regulatory authorities?
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Yes
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15. Please describe the allegation, the results including any censure, license restrictions, revocations, fines or other penalties
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16. Additional Comments
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