Property & Casualty Insurance Agents and Brokers E & O Application

Personal Information

Applicant’s Legal Entity Name *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

No. of Locations *

State(s) *

Primary Phone Number *

Website Address *

E-Mail Address *

Agency is a *

Corporation
Sole Proprietorship
Partnership
LLC
Other

Date Entity Established *

(If less than three years ago, you must attach a resume and business plan.)

Number of years industry experience of agency principal(s) *

Have you had any acquisitions, mergers or cluster arrangements within the past five (5) years? *

Yes
No

Current E&O carrier *

Retroactive Date *

Desired Eff. Date *

(ATTACH COPY OF CURRENT E&O DECLARATIONS PAGE FOR CONFIRMATION OF RETROACTIVE DATE)

Limits currently carried *

Deductible *

Premium *

Please provide the following based on the last 12 months of operation. If new agency, provide next 12 months projection.

Agency P & C premium volume *

Agency P & C commission income *

Agency Life/A & H premium volume *

Agency Life/A & H commission income *

Consulting/Broker Fees *

Mutual Funds and/or Variable Products *

Securities *

Indicate below the number of staff in your agency as follows (include owners, principals, partners, etc)

Total Licensed *

Of the total, how many are: P&C *

Of the total, how many are: L&H *

Total Unlicensed (with client contact) *

Total Contracted Non-Employee Producers *

Of the total, how many are: P&C *

Of the total, how many are: L&H *

(NOTE: PRODUCERS WITHOUT WRITTEN CONTRACTS ARE NOT COVERED.)

Total Staff Series 6 & 7 Licensed *

Average years experience Series 6 & 7 *

Has the Applicant been the subject of disciplinary action or investigation as a result of professional activities? *

Yes
No

In the past 5 years, number of E & O claims

0
1
2
3 or more

Total Amount Paid *

Does the Applicant have any knowledge of any potential errors or omissions claim(s)? *

Yes
No

Has the Applicant ever had E&O coverage declined, cancelled or refused renewal? (Not applicable in MO) *

Yes
No

(If yes to any of the above, please provide details by attachment to this application)

During the past 5 years, has the Applicant made an "adjustment" or "goodwill payment" in settlement of any dispute? *

Yes
No

(If yes, attach explanation concerning payments of $500.00 or more, exclusive of company draft authority.)

Have any employees attended an E&O loss prevention seminar or other industry related education courses within the past twelve months? *

Yes
No

(Firm may qualify for loss prevention credit. Please attach documentation of course completion.)

Percentage of business placed with Admitted carriers rated below B+, Non-Admitted carriers rated below A- by A.M. Best OR carriers that are not rated by A. M. Best *

Percentage of policies that are Direct Bill *

Percentage of policies that Insured Can Make Changes Through Carrier Service Center *

Percentage of business placed through any State Administered Work Comp Funds *

Are you a *

Retail Agent
Wholesaler
Surplus Lines Broker
MGA

Percentage of business placed direct with carriers *

Percentage of business placed through a Wholesaler or MGA *

Percentage of business placed with carriers that are admitted *

Percentage of business placed with carriers that are non-admitted *

How many wholesalers are you contracted to write business through? *

List top 5 insurance carriers business is placed with and the revenues (your commission) derived from placement

Insurance Carrier *

Revenues *

Insurance Carrier *

Revenues *

Insurance Carrier *

Revenues *

Insurance Carrier *

Revenues *

Percentage of commission income derived from personal lines *

Percentage of commission income derived from commercial lines *

Percentage of commission income derived from life & health *

Please indicate the percentage of the commission derived from each line of business listed below

THE TOTAL OF ALL LINES OF BUSINESS LISTED MUST EQUAL 100% AND MUST CORRESPOND TO THE PERCENTAGES SHOWN IN PREVIOUS QUESTION

PERSONAL LINES

Auto (Standard) *

Auto (Non-standard)/Motorcycles *

Homeowners *

Non-Standard Property *

Pleasure Boats/Craft *

Umbrella *

Other

LIFE, ACCIDENT & HEALTH

Individual Life *

Group Life *

Individual Accident & Health *

Group Accident & Health *

Fixed Annuities *

Variable Annuities *

Mutual Funds *

Securities *

Other

COMMERCIAL LINES

Property (Standard) *

Property (Non-standard) *

SMP/BOP/Package *

General Liability *

Umbrella/Excess *

Auto (Standard) *

Auto (Nonstandard) *

Long Haul Trucking *

Workers Compensation *

Livestock *

Crop *

Medical Malpractice *

Professional Liability *

Inland Marine *

Wet Marine *

Bonds – Surety *

Bonds – All Other *

Aviation *

Other

Is there any coverage placed, or involvement with or responsibility as an administrator for self-insured trusts, captives or risk retention groups, risk purchasing groups? *

Yes
No

(If yes, please provide details by attachment to this application.)

Is there any coverage placed, or involvement with or responsibility as an administrator for PEO’s, Multiple Employer Trusts (MET) or Multiple Employer Welfare Arrangements (MEWA)? *

Yes
No

(If yes, please provide details by attachment to this application.)

Office Procedures (Loss Control credits may be available in this area.)

Is proof of errors & omissions liability insurance required from agents/brokers and/or sub-agents/brokers that place business with your agency? *

Yes
No
N/A

Is there an in-house policy/procedures manual in use? *

Yes
No

Is there a procedure for documenting phone conversations? *

Yes
No

Is all incoming mail date stamped? *

Yes
No

Are there procedures that preserve the confidential nature of client’s information? *

Yes
No

Is there an in-house training program for new employees? *

Yes
No
N/A

Is there a procedure or checklist used in reviewing client coverage/limit requirements? *

Yes
No

Are written or electronic records maintained outlining details of all critical conversations, including verbal instructions and oral agreements? *

Yes
No

Does the applicant document client’s acceptance and rejection of offers, coverage, conditions and limitations? *

Yes
No

Are policies/endorsements checked against the application and other client requests for coverage prior to delivery to clients? *

Yes
No

Are umbrella/excess policies reviewed to be certain they are consistent with primary policy terms and conditions? *

Yes
No
N/A

Are expirations lists maintained? *

Yes
No

If you have answered “No” to any of the questions in "Office Procedures" above, please explain

Desired Limits of Liability (each claim/aggregate limit applies)

$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$4,000,000
Other

If Other

Desired Deductible (each claim/aggregate deductible applies)

$2,500/$7,500
$5,000/$15,000
$7,500/$15,000
Other

If Other

It is agreed that if any applicant or director, officer, manager, member, partner, employee or agent of the applicant for whom coverage is being applied for has knowledge of any information concerning any such fact, circumstance, situation, act, error or omissions, whether or not identified in response to Question 15 or 16, any claims arising therefore is hereby excluded from coverage under the policy, if issued. It is hereby agreed that the information provided above is true and correct, and is material in deciding whether to issue the above coverage to the Applicant.

MUST BE SIGNED AND DATED BY OWNER, PARTNER OR SENIOR OFFICER OF THE AGENCY APPLYING FOR COVERAGE

Name *

Title *

Date *

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Property & Casualty Insurance Agents and Brokers E & O Application

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