| Personal Information |
| Applicant’s Legal Entity Name
Required
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| First Name
Required
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| Last Name
Required
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| Street
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| No. of Locations
Required
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| State(s)
Required
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| Primary Phone Number
Required
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| Website Address
Required
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| E-Mail Address
Required
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| Agency is a
Required
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| Date Entity Established
Required
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(If less than three years ago, you must attach a resume and business plan.) |
| Number of years industry experience of agency principal(s)
Required
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| Have you had any acquisitions, mergers or cluster arrangements within the past five (5) years?
Required
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| Current E&O carrier
Required
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| Retroactive Date
Required
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| Desired Eff. Date
Required
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| (ATTACH COPY OF CURRENT E&O DECLARATIONS PAGE FOR CONFIRMATION OF RETROACTIVE DATE) |
| Limits currently carried
Required
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| Deductible
Required
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| Premium
Required
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| 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
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| Agency P & C commission income
Required
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| Agency Life/A & H premium volume
Required
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| Agency Life/A & H commission income
Required
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| Consulting/Broker Fees
Required
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| Mutual Funds and/or Variable Products
Required
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| Securities
Required
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| Indicate below the number of staff in your agency as follows (include owners, principals, partners, etc) |
| Total Licensed
Required
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| Of the total, how many are: P&C
Required
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| Of the total, how many are: L&H
Required
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| Total Unlicensed (with client contact)
Required
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| Total Contracted Non-Employee Producers
Required
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| Of the total, how many are: P&C
Required
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| Of the total, how many are: L&H
Required
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(NOTE: PRODUCERS WITHOUT WRITTEN CONTRACTS ARE NOT COVERED.) |
| Total Staff Series 6 & 7 Licensed
Required
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| Average years experience Series 6 & 7
Required
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| Has the Applicant been the subject of disciplinary action or investigation as a result of professional activities?
Required
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| In the past 5 years, number of E & O claims
Optional
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| Total Amount Paid
Required
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| Does the Applicant have any knowledge of any potential errors or omissions claim(s)?
Required
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| Has the Applicant ever had E&O coverage declined, cancelled or refused renewal? (Not applicable in MO)
Required
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| (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
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(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
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(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
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| Percentage of policies that are Direct Bill
Required
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| Percentage of policies that Insured Can Make Changes Through Carrier Service Center
Required
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| Percentage of business placed through any State Administered Work Comp Funds
Required
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| Are you a
Required
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| Percentage of business placed direct with carriers
Required
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| Percentage of business placed through a Wholesaler or MGA
Required
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| Percentage of business placed with carriers that are admitted
Required
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| Percentage of business placed with carriers that are non-admitted
Required
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| How many wholesalers are you contracted to write business through?
Required
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List top 5 insurance carriers business is placed with and the revenues (your commission) derived from placement |
| Insurance Carrier
Required
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| Revenues
Required
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| Insurance Carrier
Required
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| Revenues
Required
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| Insurance Carrier
Required
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| Revenues
Required
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| Insurance Carrier
Required
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| Revenues
Required
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| Percentage of commission income derived from personal lines
Required
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| Percentage of commission income derived from commercial lines
Required
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| Percentage of commission income derived from life & health
Required
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Please indicate the percentage of the commission derived from each line of business listed below |
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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
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| Auto (Non-standard)/Motorcycles
Required
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| Homeowners
Required
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| Non-Standard Property
Required
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| Pleasure Boats/Craft
Required
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| Umbrella
Required
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| Other
Optional
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| LIFE, ACCIDENT & HEALTH |
| Individual Life
Required
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| Group Life
Required
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| Individual Accident & Health
Required
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| Group Accident & Health
Required
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| Fixed Annuities
Required
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| Variable Annuities
Required
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| Mutual Funds
Required
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| Securities
Required
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| Other
Optional
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| COMMERCIAL LINES |
| Property (Standard)
Required
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| Property (Non-standard)
Required
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| SMP/BOP/Package
Required
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| General Liability
Required
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| Umbrella/Excess
Required
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| Auto (Standard)
Required
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| Auto (Nonstandard)
Required
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| Long Haul Trucking
Required
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| Workers Compensation
Required
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| Livestock
Required
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| Crop
Required
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| Medical Malpractice
Required
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| Professional Liability
Required
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| Inland Marine
Required
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| Wet Marine
Required
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| Bonds – Surety
Required
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| Bonds – All Other
Required
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| Aviation
Required
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| Other
Optional
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| 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
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(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
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(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
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| Is there an in-house policy/procedures manual in use?
Required
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| Is there a procedure for documenting phone conversations?
Required
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| Is all incoming mail date stamped?
Required
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| Are there procedures that preserve the confidential nature of client’s information?
Required
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| Is there an in-house training program for new employees?
Required
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| Is there a procedure or checklist used in reviewing client coverage/limit requirements?
Required
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| Are written or electronic records maintained outlining details of all critical conversations, including verbal instructions and oral agreements?
Required
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| Does the applicant document client’s acceptance and rejection of offers, coverage, conditions and limitations?
Required
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| Are policies/endorsements checked against the application and other client requests for coverage prior to delivery to clients?
Required
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| Are umbrella/excess policies reviewed to be certain they are consistent with primary policy terms and conditions?
Required
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| Are expirations lists maintained?
Required
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| If you have answered “No” to any of the questions in "Office Procedures" above, please explain
Optional
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| Desired Limits of Liability (each claim/aggregate limit applies)
Optional
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| If Other
Optional
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| Desired Deductible (each claim/aggregate deductible applies)
Optional
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| If Other
Optional
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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
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| Title
Required
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| Date
Required
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| Upload File
Optional
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| Upload File
Optional
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| Upload File
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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