INSURANCE AGENT & BROKER PROFESIONAL LIABILITY APPLICATION Instructions: Please answer all questions. If the answer is none, state none. If the answer is not applicable state N/A. If the space provided is insufficient to fully answer the question, please attach a separate sheet. Note: Application must be dated and signed by owner, partner, officer, or administrator of the First Named Insured. The application, its attachments and all previous applications and their attachments shall serve as the basis of the policy, and shall become part of such policy should a policy be issued, as if physically attached. The Company relies upon the application in issuing the policy. Completion of this application does not in any way imply such coverage under the policy. Coverage is afforded only if and to the extent indicated by the terms and conditions of the policy if issued. I. APPLICANT INFORMATION Applicant s legal entity name: (proposed First Named Insured) Physical street address: City: State: Zip: County: Phone: Fax: Email: Contact name: Website: II. AGENCY OPERATIONS 1. a. Does Applicant have any other locations in addition to the location shown in Section I. above? Yes No If Yes, please attach an explanation. 2. Is coverage requested for any majority owned additional insurance agency entities or trade names (DBA entities) that should be listed on the policy? Yes No If Yes, please attach an explanation. 3. Applicant Organization Type: Individual Partnership Corporation LLC Other: 4. Is Applicant s agency part of a franchise? Yes No If Yes, list franchise: 5. What year was Applicant s agency established? 6. Indicate license(s) held by Applicant agency or agency personnel: Agent/Agency MGA Broker Surplus Lines Broker Consultant Third Party Administrator Other professional licenses: 7. Indicate Applicant s number of personnel: (each individual should only be counted once) Full Time Part Time Active owners, officers, partners Licensed employee solicitors, brokers, agents Licensed independent contractors Clerical Other (please specify): Total Staff 8. Indicate the following: Last 12 Months Next 12 Months (Estimated) Total P&C new and renewal annual written premiums Total P&C new and renewal annual commissions Total Life and A&H new and renewal annual commissions 8172017 Page 1 of 5
9. List the top three agency-contracted Property & Casualty Insurance carriers by annual premium: Complete Name of Insurance Carrier Years Represented Annual Premium 10. Have any carriers terminated your contract for reasons other than for lack of production or market withdrawal in the last five years? Yes No If Yes, attach a full explanation for each. 11. Does Applicant s agency place insurance in more than three non-resident states? Yes No If Yes, do the agency personnel have more than three years of experience placing coverage in those states? Yes No 12. Indicate percentage of Property & Casualty business Applicant places (Enter N/A if Not Applicable) (Total must equal 100%): a. Directly with carriers (other than as a broker, MGA or surplus lines broker): % b. Through any other third party (i.e., a wholesaler, surplus lines broker, other retail agencies): % 13. Indicate current year mix of Applicant s business placed by total premium volume: P&C Commercial Lines (Total P&C Premiums) Premium Volume Life Insurance & Annuities Commission Commercial Auto $ Annuities Non-variable $ BOP/CGL/Package $ Annuities - Variable $ Umbrella/Excess $ Credit Life $ Property $ Group $ Crop $ Individual $ Workers Compensation $ Mutual Funds $ Flood $ Other (describe): $ Wet Marine $ A&H Insurance Livestock Mortality $ Group Carrier Insured $ Medical Malpractice $ Group Self Insured $ Professional Liability Non-Medical $ HMO/PPO/DSP $ Aviation $ Individual $ Bonds Surety/Contract $ Disability Individual $ Bonds Other $ Disability Group $ Long Haul Trucking $ Other (describe): $ Risk Retention Plans $ Total Life, Annuities, A&H Commission $ Other (describe): $ Total Commercial Lines Premium $ Personal Lines Auto Standard $ Auto Non-Standard $ Auto Assigned Risk $ Homeowners & Standard Fire $ Non-Standard Fire/FAIR Plan $ Watercraft $ Umbrella $ Flood $ Farmowners $ Other (describe): $ Total Personal Lines Premium $ Commercial + Personal Premium $ Premium Volume 8172017 Page 2 of 5
14. In the past five years, has the Applicant placed coverage for any petroleum exposures, including, but not limited to, service, extraction, exploration, development, production, transportation, delivery, or storage thereof? Yes No If Yes, indicate: Number of accounts: Annual premium: 15. In the past five years, has the Applicant placed coverage for hazardous waste removal, storage or treatment? Yes No If Yes, indicate: Number of accounts: Annual premium: 16. Does the Applicant derive income from any activity or profession other than the sale of insurance products?? Yes No If Yes, please attach a description of each activity or profession including the percentage of Applicant s total income derived from it. 17. a. Is there any entity having a 10% or more ownership interest in the Applicant s agency or any subsidiary or affiliate of the Applicant s agency? Yes No b. Entity s Name: c. Ownership: % d. Entity s Operations: Bank Insurance Real Estate/Mortgage Other: e. Entity s Affiliation: Parent Company Sister Company Holding Company Joint Venture f. What percentage of Applicant s revenue is derived from insurance placement for affiliated companies? % 18. a. Does Applicant place insurance for any entity (other than the Applicant) which the Applicant or Applicant s personnel operates, controls or manages or have 10% or more ownership interest? Yes No b. Does Applicant place insurance for any entity (other than the Applicant) in which the Applicant s personnel is an officer or director? Yes No 19. Office procedures for all locations: a. Are incoming documents date identified? Yes No b. Does the Applicant maintain a policy expiration list? Yes No c. Is there a procedure to use a coverage checklist on commercial proposals? Yes No d. Is there a procedure to maintain written documentation of all rejections of coverage? Yes No e. Is there a procedure to periodically review renewal risks for needed changes in coverage? Yes No f. Is there a procedure to document that policies and endorsements are checked for accuracy prior to delivery? Yes No g. Is there a procedure for documenting telephone conversations? Yes No h. Does the agency use a diary/suspense/follow up procedure? Yes No i. Does Applicant maintain binder logs? Yes No III. CLAIMS AND/OR INCIDENTS 1. Potential Claims Is any owner, partner, officer, director, employee, or independent contractor aware of any circumstance, allegation, contention, or incident which may result in a claim being made against the agency, its predecessors (s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? Yes No If Yes, provide details on the separate Supplemental Claims Application. 2. Actual Claims During the past five years, has any claim been made or suit brought against the agency, its predecessors (s) in business, or any of its present or former owners, partners, officers, directors, employees, or independent contractors? Yes No If Yes, provide details on the separate Supplemental Claims Application. 8172017 Page 3 of 5
3. Has any policy or application for errors and omissions insurance on behalf of the Applicant or any of its past or present owners, officers, partners or employees or solicitors, or to the knowledge of the Applicant, on behalf of its predecessors in business, ever been declined, canceled or renewal refused, within the last five years? Yes No If Yes, provide details: 4. In the last five years, have any past or present Applicant personnel been the subject of complaints filed, investigations and/or disciplinary action by any insurance or other regulatory authority or convicted of a criminal activity? Yes No If Yes, provide a copy of the action pending or taken by the disciplinary body or judicial system. IV. REQUESTED INSURANCE 1. Please provide the following details of the Applicant s prior three years of professional liability insurance. Indicate None if none. Name of Carrier Expiration Date Limit Each Claim Deductible Each Claim Premium Policy Retro Date (if Full Prior Acts, check box) 2. Requested Effective Date: V. ADDITIONAL REMARKS FRAUD NOTICE 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 THAT PERSON TO CRIMINAL AND CIVIL PENALTIES. (Not applicable in AL, AR, CA, CO, DC, FL, KS, KY, LA, MD, ME, NH, NJ, NM, NY, OH, OK, OR, RI, TN, VA, VT, WA or WV see Additional Fraud Notices attached hereto for these States). NOTICE TO APPLICANT For the purpose of this application, the undersigned applicant declares that, to the best of his or her knowledge, the statements herein are true and complete. The Insurer is authorized to make any inquiry in connection with this application. Signing this application does not bind the Insurer to issue, or the applicant to purchase, any insurance policy. The information contained in and submitted with this application is on file with the Insurer. This application will become a part of such policy if issued. The Insurer will have relied upon this application and attachments (if any) in issuing this policy. If the information in this application materially changes prior to the effective date of the policy, the applicant must notify the Insurer, who may modify or withdraw the quote. 8172017 Page 4 of 5
SIGNATURES Applicant s Signature* Date Producer s Signature Date Print or type applicant s name Applicant s Title Must be signed by a duly authorized officer of the Applicant on behalf of all insureds ADDITIONAL FRAUD NOTICES 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 TO DEFRAUD 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 IN 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 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND 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 MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. 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. 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 INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. 8172017 Page 5 of 5