Agents E&O Quick Application
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly. Email any additional information to INSURANCE@USEO.COM or fax additional information to 713-984-1152. Call 800-460-6424 for any questions.
Basic Information
State *
Premium Volume
Commissions
Last Year
INDICATE THE PERCENTAGE OF TOTAL COMMISSION INCOME THE AGENCY PLACES IN THE FOLLOWING CLASSES OF BUSINESS:
Type of Carrier
Next 12 Year Estimate of Gross Commission Income
Agency Information
If "Yes" to the question above, please provide claim information below and fax or email your 5 year loss run to us:
If "Yes" to the question above, please provide an explanation below:
Expiration Date
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submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
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party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
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