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E&O Claim Intake
Is This A Personal Or Commercial Account?
Personal
Commercial
CLIENT INFORMATION
Business Name
Client Name (Or Commercial Contact)
First
Last
Carrier(s)
If More Than One Carrier, Separate using ” | “
Policy Number(s)
If More Than One Policy, Separate using ” | “
Line Of Business(s)
If More Than One Line Of Business, Separate using ” | “
AGENCY INFORMATION
Who Is Completing This Form?
Agent(s) Involved
If More Than One Line Of Business, Separate using ” | “
INCIDENT INFORMATION
Date Issue Occurred (Approximate If Not Known)
MM slash DD slash YYYY
Date Issue Discovered Or Reported
MM slash DD slash YYYY
How Was Issue Discovered?
Client Communication
Carrier Communication
Internal Review
Other
Incident Description (Facts Only)
Describe what occurred in chronological order. Facts only – no opinions or conclusions.
Alleged Or Actual Client Impact
Describe any claimed or known client impact
Coverage Details
Coverage allegedly missing or incorrect: Was coverage originally requested? (Yes / No / Unknown):
Client Communication?
Has the client been contacted? (Yes / No): If yes, summarize communication:
Immediate Risk Assessment (Facts Only)
Any pending deadlines or time-sensitive exposure:
Do We Have All Of The Following Ready For Review?
Do You Have Call Recordings?
Email Communications
Text Communications
Original Applications
Endorsements
Endorsement Requests
Carrier Correspondence
Select All
Please Select All Applicable Items And Forward To Management
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