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Property & Casualty Insurance Agents and Brokers E & O Application





Personal Information
Applicant’s Legal Entity Name
Required
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
No. of Locations
Required
State(s)
Required
Primary Phone Number
Required
Website Address
Required
E-Mail Address
Required
Agency is a
Required




Date Entity Established
Required
(If less than three years ago, you must attach a resume and business plan.)
Number of years industry experience of agency principal(s)
Required
Have you had any acquisitions, mergers or cluster arrangements within the past five (5) years?
Required

Current E&O carrier
Required
Retroactive Date
Required
Desired Eff. Date
Required
(ATTACH COPY OF CURRENT E&O DECLARATIONS PAGE FOR CONFIRMATION OF RETROACTIVE DATE)
Limits currently carried
Required
Deductible
Required
Premium
Required
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
Required
Agency P & C commission income
Required
Agency Life/A & H premium volume
Required
Agency Life/A & H commission income
Required
Consulting/Broker Fees
Required
Mutual Funds and/or Variable Products
Required
Securities
Required
Indicate below the number of staff in your agency as follows (include owners, principals, partners, etc)
Total Licensed
Required
Of the total, how many are: P&C
Required
Of the total, how many are: L&H
Required
Total Unlicensed (with client contact)
Required
Total Contracted Non-Employee Producers
Required
Of the total, how many are: P&C
Required
Of the total, how many are: L&H
Required
(NOTE: PRODUCERS WITHOUT WRITTEN CONTRACTS ARE NOT COVERED.)
Total Staff Series 6 & 7 Licensed
Required
Average years experience Series 6 & 7
Required
Has the Applicant been the subject of disciplinary action or investigation as a result of professional activities?
Required

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



Total Amount Paid
Required
Does the Applicant have any knowledge of any potential errors or omissions claim(s)?
Required

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

(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?
Required

(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?
Required

(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
Required
Percentage of policies that are Direct Bill
Required
Percentage of policies that Insured Can Make Changes Through Carrier Service Center
Required
Percentage of business placed through any State Administered Work Comp Funds
Required
Are you a
Required



Percentage of business placed direct with carriers
Required
Percentage of business placed through a Wholesaler or MGA
Required
Percentage of business placed with carriers that are admitted
Required
Percentage of business placed with carriers that are non-admitted
Required
How many wholesalers are you contracted to write business through?
Required
List top 5 insurance carriers business is placed with and the revenues (your commission) derived from placement
Insurance Carrier
Required
Revenues
Required
Insurance Carrier
Required
Revenues
Required
Insurance Carrier
Required
Revenues
Required
Insurance Carrier
Required
Revenues
Required
Percentage of commission income derived from personal lines
Required
Percentage of commission income derived from commercial lines
Required
Percentage of commission income derived from life & health
Required
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)
Required
Auto (Non-standard)/Motorcycles
Required
Homeowners
Required
Non-Standard Property
Required
Pleasure Boats/Craft
Required
Umbrella
Required
Other
Optional
LIFE, ACCIDENT & HEALTH
Individual Life
Required
Group Life
Required
Individual Accident & Health
Required
Group Accident & Health
Required
Fixed Annuities
Required
Variable Annuities
Required
Mutual Funds
Required
Securities
Required
Other
Optional
COMMERCIAL LINES
Property (Standard)
Required
Property (Non-standard)
Required
SMP/BOP/Package
Required
General Liability
Required
Umbrella/Excess
Required
Auto (Standard)
Required
Auto (Nonstandard)
Required
Long Haul Trucking
Required
Workers Compensation
Required
Livestock
Required
Crop
Required
Medical Malpractice
Required
Professional Liability
Required
Inland Marine
Required
Wet Marine
Required
Bonds – Surety
Required
Bonds – All Other
Required
Aviation
Required
Other
Optional
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?
Required

(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)?
Required

(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?
Required


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

Is there a procedure for documenting phone conversations?
Required

Is all incoming mail date stamped?
Required

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

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


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

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

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

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

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


Are expirations lists maintained?
Required

If you have answered “No” to any of the questions in "Office Procedures" above, please explain
Optional
Desired Limits of Liability (each claim/aggregate limit applies)
Optional




If Other
Optional
Desired Deductible (each claim/aggregate deductible applies)
Optional



If Other
Optional
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
Required
Title
Required
Date
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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