1. APPLICANT INFORMATION (a) Applicant Name DBA (if any) (f) Website Year Established (g) # of Additional Locations*: (h) Mailing Address (i) Staff:

Transcription

1 ALLIED WORLD SURPLUS LINES INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT Tel. (860) Fax (860) APPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY INSURANCE POLICY NOTICE: THE POLICY BEING APPLIED FOR IS A CLAIMS MADE POLICY WHICH APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD AND REPORTED IN WRITING TO THE INSURER PURSUANT TO THE TERMS HEREIN. WITH RESPECT TO INSURING AGREEMENT B., THE LIMIT OF LIABILITY WILL BE REDUCED AND MAY BE EXHAUSTED BY THE PAYMENT OF BOTH LOSS AND DEFENSE EXPENSES. PLEASE READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING. 1. APPLICANT INFORMATION (a) Applicant Name DBA (if any) (b) Physical Address (d) City/State/Zip (c) Risk Manager (e) Risk Manager (f) Website Year Established (g) # of Additional Locations*: (h) Mailing Address (i) Staff: Owners, Officers, Partners Employed Solicitors, Brokers, Agents All Other Employees TOTAL STAFF: *Attach a list of locations, if applicable Exclusive n-employee Producers n-exclusive, n-employee Producers 2. OWNERSHIP & SUBSIDIARIES (a) Is the applicant controlled, owned (in whole or in part) by any other entity? If yes, provide the name of the entity: (b) Please list all subsidiaries or affiliates (attach a separate sheet if necessary): Name of Subsidiary or Affiliate Relationship to the Applicant % Owned by Applicant Type of Services Provided Coverage desired? % % % During the past 5 years: (c) Has the name of the Applicant been changed, or has any business/firm been acquired, merged into, consolidated or sold off by/from the original firm? (d) Has there been any change in management structure, including any additions or deletions of any principals, owners, managers or brokers? (e) Has the Applicant participated in any cluster arrangements? If yes to c, d or e above, please explain: (attach a separate sheet if necessary) Page 1 of

2 3. OPERATIONS (a) What percent of the Applicant s revenue is derived from professional services performed as: Insurance Agent or Broker % Managing General Agent/Underwriter* % Reinsurance Intermediary % Other: % Total must = 100% 100 % (b) What percent of the Applicant s revenue is derived from: Business received directly from the client % Business received from another insurance agent or broker % Total must = 100% 100 % (c) What percent of the Applicant s revenue is derived from professional services provided outside of the United States? % *If any business is placed as an MGA/MGU, please complete and attach the Managing General Agent/ Underwriter Supplemental Application 4. WRITTEN PREMIUM & REVENUE (a) (b) (c) (d) (e) Written Premium & Revenue Total Annual Property & Casualty Gross Written Premium Total Annual Property & Casualty Gross Commissions Total Annual Life, Accident & Health Gross Written Premium Total Annual Life, Accident & Health Gross Commissions Total Annual Income Derived From Other Insurance Related Activities* See below Previous 36 Months Previous 24 Months Current 12 Months Estimated Next 12 Months (f) *Other Insurance Related Activities: Does the applicant provide any of the following Professional Service? If yes, provide the gross revenue derived from these services. If services are provided for no additional fee and included in the commission amounts shown in items 4b or 4d above, please write included. Services Provided? Annual Gross Revenue (should = 4e) Third Party Administrator* Claims Adjustment Services* Investment/Securities Advisor Benefit Plan Administrator Actuarial Services Legal Advice/Services Tax Advice Risk Management/Loss Control Title Insurance Premium Finance Other: *If yes to TPA or Claims Adjustment Services, please complete and attach the Third Party Administration & Claims Administrative Services Supplemental Application. Page 2 of

3 5. LINES OF BUSINESS (a) Property & Casualty Lines: Gross written premium volume for the Current 12 months: (note: totals must = 4a) COMMERCIAL LINES PREMIUM CMP/Package Medical Malpractice CGL/BOP Wet Marine Umbrella/Excess Inland Marine Auto Standard Bonds/Surety Auto- n-standard Aviation Long Haul Trucking Products Liability Workers Compensation Other (specify) Livestock Mortality Crop Coverages Professional Liability (specify) TOTAL COMMERCIAL LINES PERSONAL LINES PREMIUM Auto-Standard Motorcycles Auto- n Standard Wind/Flood/Earthquake Homeowners Umbrella n Standard Fire Other (specify) Pleasure Boats Mobile Home/RVs TOTAL PERSONAL LINES (b) Life, Accident & Health Lines: Gross commissions for the Current 12 months: (note: totals must = 4d) LIFE, ACCIDENT & HEALTH COMMISSIONS Life, Individual A&H Individual A&H Individual A&H Group Other (specify) Annuities TOTAL LA&H (c) In the past five (5) years, has the Applicant specialized in any programs or classes of business? If yes, provide details: (d) Does the Applicant currently place any mutual funds? If yes, what is the annual revenue derived from these placements? (e) In the past five (5) years, has the Applicant placed any securities other than variable annuities, variable life insurance or mutual funds? If yes, provide details: 6. CARRIERS & PLACEMENTS (a) List the current top five (5) insurance carriers for whom you produce premium: Insurance Carrier Years Represented Annual Premium Volume Current AM Best Rating Page 3 of

4 (b) What percentage of business is placed with: Carriers Rated B or Less by A.M. Best % Admitted Carriers % Carriers t Rated by A.M. Best % n-admitted Carriers % (c) In the past three (3) years, has the Applicant placed any coverage with any carriers currently rated NR or B or less by A.M. Best? (If yes, please list all. Attach separate sheet if necessary.) Insurance Carrier Years Represented Annual Premium Volume Current AM Best Rating (d) If yes to 6 (c), provide an explanation regarding the protocol for placements made with carriers that are not rated or are rated lower than B. (e) What is the Applicant s protocol for tracking carrier ratings throughout the year and notifying clients of any adverse changes in a carrier s rating? (f) List all insurance carriers with whom agency contracts have been terminated in the last 5 years and provide a reason for each termination. (If none, state none ) (g) Does the Applicant have any involvement in the following entities? Check all that apply Entity Type Ownership/ Operation/ Establishment Administration Place business with Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Accountable Care Organization (ACO) Self-Insurance Program Captive Insurer Multi-Employer Trust (MET) Risk Retention Group (RRG) Risk Purchasing Group (RPG) If yes to any, please provide an explanation: 7. RISK MANAGEMENT, OFFICE CONTROLS AND PROCEDURES (a) Is it standard office procedure to: Date stamp incoming mail? Document all telephone conversations? Maintain a policy expiration list? Check all applications, policies and endorsements for accuracy? Maintain a diary/suspense system? Obtain written signoff from clients for all coverages accepted and rejected? Disclose any fees charged to the clients prior to binding the policies? Page 4 of 9

5 Prohibit all employees from signing any applications on behalf of the client? If no to any, please provide an explanation: (b) Are the policies & procedures outlined in Question 7a. documented in a manual? 8. PRIVACY & NETWORK SECURITY (a) Please quantify (by number of individual records) the Personally Identifiable Information (PII)* the Applicant currently stores, processes or transacts within its Network. (If unable to provide an exact number, please provide a best estimate, and describe the methodology for arriving at this estimate.) *Personally Identifiable Information is information from which an individual may be uniquely and reliably identified, including, but not limited to an individual's name, address, telephone number, in combination with their social security number, account relationships, account numbers, passwords, PIN numbers, credit or debit card numbers, biometric information, npublic Personal Information as defined by the Gramm-Leach Bliley Act of 1999, or Personal Health Information ( PHI ) as defined by the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). NOTE: All information for a single client counts as one (1) record. For example, if the Name, Address, Phone Number and Social Security number for one client are stored, it should be counted as 1 record, not 4 records. (b) Do all laptop computers have whole disk encryption? (c) Does the Applicant currently handle, accept, process, store, or transmit any payment by credit, debit or ATM cards (whether directly or through a third party service provider)? If yes, are you compliant with the most recent Payment Card Industry Data Security Standards (PCI-DDS)? If yes, what is the highest level you are required to adhere to for any card brand? (d) What is the Applicant s current wireless network security protocol? If you do not have a wireless network, select N/A WPA WPA2 N/A (e) Does the Applicant always use encryption to protect information stored on backup tapes? If an alternative method other than backup tapes is used, select N/A and provide an explanation: (f) Do the responses to all questions in section 8 apply to all Applicant operations, including all subsidiary operations? If no, please explain: 9. CLAIMS & DISCIPLINE (a) Has any prospective insured, or any of its employees, ever been subject to an investigation by a state regulatory agency, administrative agency and/or an insurance department investigation or inquiry or disciplinary investigation or proceeding in any way? (b) Has any prospective insured, or any of its employees, ever had their license revoked, suspended, or been fined or disciplined by any state or regulatory department? (c) During the past five (5) years, has any claim or notice of claim been made or suit brought against the Applicant, its predecessor (s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? Page 5 of 9

6 (d) Is the Applicant, its predecessor (s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors aware of any fact, circumstance, situation, allegation, contention or incident which may result in a claim being made against the Applicant, its predecessor (s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? If yes to any question in Section 9, a completed Claims Supplemental Application must be completed and attached. WITH REGARD TO QUESTIONS 9 (c) AND 9 (d) IT IS UNDERSTOOD AND AGREED THAT, WITHOUT LIMITING ANY RIGHTS OF THE INSURER, IF SUCH KNOWLEDGE OR INFORMATION EXISTS, ANY CLAIM ARISING THEREFROM IS EXCLUDED FROM THIS PROPOSED INSURANCE. 10. INSURANCE INFORMATION (a) Professional Liability Insurance History: If no insurance currently inforce please check here. Effective Policy Term Carrier Limits Retention Premium Retro Date Date Current/Expiring 1 st Prior Year 2 nd Prior Year 3 rd Prior Year 4 th Prior Year (b) Has any policy or application for Errors and Omission insurance on behalf of the Applicant, its predecessor(s), or any of its present or former owners, partners, officers, directors, employees or independent contractors ever been declined, cancelled or renewal refused within the last five (5) years? If, please provide an explanation: 11. NOTICES AND REPRESENTATIONS The undersigned authorized representative of the Applicant declares that the statements set forth herein are true, and reasonable effort has been made to obtain sufficient information from all persons proposed for this insurance to facilitate the accurate completion of the Application. The undersigned authorized representative agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, he/she will, in order for the information to be accurate on the effective date of the insurance, immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or agreement to bind insurance. The submission of this Application by the Applicant to the Insurer or signing of this Application by or on behalf of the Applicant does not obligate the Insurer to issue the insurance requested. It is agreed that this Application shall be the basis of the contract if a policy is issued and shall be deemed to be attached to, incorporated into and become a part of, the policy. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE. Page 6 of 9

7 NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF. NOTICE TO ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TODEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: "WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT." NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS." NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW MEXICO APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES." Page 7 of 9

8 NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: "WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY" (365: , ). NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW." NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO RHODE ISLAND APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO TENNESSEE APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS." NOTICE TO TEXAS APPLICANTS: ANY PERSON WHO KNOWLINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. NOTICE TO VERMONT APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW." NOTICE TO VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO WASHINGTON APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS." NOTICE TO WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS OR THE BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO ALL OTHER APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS." Page 8 of 9

9 This application must be signed and dated by an Owner, Partner or Principal as duly authorized on behalf of the Applicant. The undersigned authorized representative of the Applicant declares that the statements set forth herein are true, and reasonable effort has been made to obtain sufficient information from all persons proposed for this insurance to facilitate the accurate completion of the Application. Signature of Owner, Partner or Principal Date Print Name Title Licensed Agent License Number Page 9 of 9