RLI TRANSPORTATION A Division of RLI Insurance Company 2970 Clairmont Road, Suite 1000 Atlanta, GA 30329 Phone: 404-315-9515 Fax: 404-315-6558 AGENCY/BROKER PROFILE Please type your answers. Use a separate answer sheet if necessary. A. GENERAL INFORMATION NAME OF FIRM: PRINCIPAL ADDRESS: MAILING ADDRESS: PHONE: FAX:_ 800:_ E-MAIL ADDRESS: TYPE OF ENTITY: FEDERAL ID NUMBER: [ ]CORPORATION [ ]PARTNERSHIP [ ]INDIVIDUAL B. BACKGROUND YEAR BUSINESS ESTABLISHED: DURING THE PAST FIVE YEARS HAS THE FIRM ACQUIRED/MERGED WITH ANOTHER FIRM OR HAS THE FIRM CHANGED NAMES? [ ]YES [ ]NO IF YES, PLEASE DESCRIBE: IS FIRM ENGAGED IN, OWNED BY, ASSOCIATED OR AFFILIATED WITH, OR CONTROLLED BY ANY OTHER BUSINESS INTEREST? [ ]YES [ ]NO IF YES, PLEASE EXPLAIN: ARE YOU A MEMBER OF: [ ]ATA [ ]MCA [ ]OTHER IF OTHER, PLEASE LIST:_ C. PRINCIPALS AND PERSONNEL BREAKDOWN OF PRODUCER S STAFF (Number): Current Year Prior Year PRINCIPALS, PARTNERS, OWNERS: OFFICERS, MANAGERS: BROKERS (Other than above): UNDERWRITERS: OTHER EMPLOYEES: TOTAL STAFF: 1
PRINCIPALS, OFFICERS, BROKERS LIST IN ORDER OF PERCENTAGE OF OWNERSHIP: NAME TITLE OR POSITION YEAR STARTED IN INSURANCE YEAR STARTED WITH PRODUCER PERCENT OWNERSHIP D. OPERATIONS DOES YOUR FIRM OPERATE AS A WHOLESALER, MGA, RETAILER OR COMBINATION? % RETAIL % WHOLESALE BROKERAGE % MGA BINDING AUTHORITY HOW IS YOUR ORGAINZATION LICENSED, I.E., EXCESS AND SURPLUS LINES BROKER, REINSURANCE INTERMEDIARY, OR OTHER INSURANCE/REINSURANCE ORGANIZATION? LIST STATES WITH LICENSES: AL In-Force # Brokers (Yes / No) KY In-Force (Yes / No) # Brokers ND AK LA OH AZ ME OK AR MD OR CA MA PA CO MI RI CT MN SC DE MS SD DC MO TN FL MT TX GA NE UT HI NV VT ID NH VA IL NJ WA IN NM WV IA NY WI KS NC WY In-Force # Brokers (Yes / No) IF YOU ARE AN MGA, DO THE RETAIL AGENTS/BROKERS FOR WHOM YOU PLACE BUSINESS SIGN A CONTRACT REGARDING SUBMISSION OF BUSINESS AND PAYMENT OF PREMIUM? [ ]YES [ ]NO IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT. 2
E. PREMIUM VOLUME AND DISTRIBUTION YOUR TOTAL VOLUME OF BUSINESS: PRIOR CURRENT NEXT YEAR COMMERCIAL AUTO (Liability) Large Fleet Truck (26+ power units) Small Fleet Truck (1-25 power units) Public Auto COMMERCIAL AUTO (Physical Damage) Large Fleet Truck (26+ power units) Small Fleet Truck (1-25 power units) Public Auto CARGO GENERAL LIABILITY EXCESS & UMBRELLA WORK COMP & OCC ACC PROPERTY OTHER Please Describe: LIST MAJOR COMPANIES IN ORDER OF PREMIUM VOLUME: NAME YEARS REPRESENTED ANNUAL VOLUME LOSS RATIO BINDING AUTHORITY (YES / NO) NUMBER YEARS DESCRIBE SCOPE OF BINDING AUTHORITY. I.E.: LIMIT OF AUTHORITY, LINES, ETC. COMPANIES DISCONTINUED IN THE LAST FIVE YEARS: 3
DO YOU ADJUST CLAIMS FOR ANY COMPANIES YOU REPRESENT? [ ]YES [ ]NO IF YES, PLEASE EXPLAIN: DESCRIBE ANY SAFETY OR LOSS CONTROL SERVICES PROVIDED BY YOUR ENTITY: F. PRODUCTION TO COMPANY ANTICIPATED VOLUME TO COMPANY WILL COME FROM THE FOLLOWING SOURCES: LF TRUCK SF TRUCK PUBLIC AUTO (26+ Units) (1-25 Units) NEW BUSINESS TRANSFER FROM CURRENT COMPANY TRANSFER FROM DISCONTINUED COMPANY TOTAL (1+2+3) COMMENTS: G. FINANCIAL INFORMATION IF NOT HANDLED BY MAIN OFFICE, PROVIDE ADDRESS: ADDRESS: PHONE: FAX:_ 800:_ E-MAIL ADDRESS: NAME OF ACCOUNTING CONTACT: BANK REFERENCE: NAME: TRUST ACCOUNT #: OTHER: BANK ADDRESS: BANK CONTACT: PHONE: ATTACH COPY OF LATEST FINANCIAL STATEMENT. DO YOU MAINTAIN FIDELITY COVERAGE? ARE OFFICERS COVERED? [ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING: INSURANCE COMPANY:_ POLICY LIMITS: POLICY DEDUCTIBLE: EXPIRATION DATE: 4
DO YOU MAINTAIN E & O COVERAGE? [ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING: INSURANCE COMPANY:_ POLICY LIMITS: POLICY DEDUCTIBLE: EXPIRATION DATE: 7. HAS ANY MEMBER OF YOUR FIRM RECEIVED ANY DISCIPLINARY ACTION BY A STATE INSURANCE DEPARTMENT OR OTHER REGULATORY AUTHORITY? [ ]YES [ ]NO IF YES, EXPLAIN:_ 8. IS THERE ANY PENDING OR THREATENED LITIGATION OR JUDGEMENTS WITHIN THE PAST FIVE YEARS EXCEEDING $10,000 AGAINST THE BROKER OR ANY OF THE PRINCIPALS? [ ]YES [ ]NO IF YES, EXPLAIN: THE UNDERSIGNED HEREBY DECLARES THAT THE ANSWERS GIVEN WITH RESPECT TO THE FOREGOING QUESTIONS ARE TRUE, COMPLETE AND ACCURATE WITH NO MISREPRESENTATIONS, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT. SIGNATURE OF APPLICANT:_ TITLE OF APPLICANT: DATE OF SIGNATURE: ***** BE SURE TO INCLUDE COPIES OF THE FOLLOWING DOCUMENTS: LICENSES FINANCIALS P&L AND BALANCE SHEET E & O DEC PAGE RETURN TO: ATTENTION: LICENSING RLI TRANSPORTATION 2970 CLAIRMONT ROAD, SUITE 1000 ATLANTA, GA 30329 5