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Insurance Agents and Brokers Professional Liability Application
Date: 
Part I - Agency Details
1.  Agency Name:  
   Home Office Address:  
     
   Date Established:    Telephone Number:  
   Please list addresses of Branch Offices and Subsidiaries on a separate sheet.
2.  Is the applicant firm controlled, owned, affiliated or associated with any other firm corporation or company?
     Yes     No    If Yes, please attach an explanation.
3.  During the past 5 years has the name of the firm been changed or has any other business been acquired, merged
   into, or consolidated with the original firm?   Yes     No    If Yes, please attach an explanation.
4.  How many agents/brokers employed? 
   How many independent contractors (sub-agent/broker/solicitor)? 
   If Agency has been in operation less than three (3) years, please answer the following:
   Of the agents/brokers and independent contractors listed above, indicate years of experience below:
     Less than one year       1-5 years       5+ years
Part II - Agency Operations
5. a)  Please give the approximate percentage breakdown of the total of your premium volume and fees as:
     "Retail Agent"    %  (Business placed directly with Insurance Companies, JUA's or assigned
   risk pools, etc.)
   "Retail Broker"    %  (Business placed through other agents, MGA's, Wholesalers, etc.)
   "Wholesale Broker"    %  (Business received from other non-employee or contract Brokers or Agents
   and placed by your agency)
   "Other" (explain)    %  
   Must total 100%
  b)  During the past 5 years, were the above percentages for "Wholesale Broker" or "Other" higher than 10% in
     any single annual period?   Yes     No
     If Yes, please attach an explanation including the percentage breakdown of premium volume per year.
6.  Do you derive income from any activity/profession other than the sale of Insurance Products?   Yes     No
   If Yes, please attach an explanation including the percentage of your total annual income derived from it.
7.  Do you currently act or have you acted in the past five years as an MGA, Thrid Party Administrator,
   Reinsurance Intermediary, or provided services for a fee as a risk Manager/Consultant?   Yes     No
   If Yes, please attach an explanation including the percentage of your total annual premium volume derived from it.
8. a)  List ALL Insurance Companies with which your Agency places business (Use attachment if necessary):
    Insurance Company Direct Placement? Total Annual Premium Volume AM Best Rating Admitted Carrier?
     Yes     No    Yes     No
     Yes     No    Yes     No
     Yes     No    Yes     No
     Yes     No    Yes     No
     Yes     No    Yes     No
     Yes     No    Yes     No
     Yes     No    Yes     No
  b)  Other than the companies listed in question 8A, has coverage been placed with any unrated, non-admitted or
     alien Insurance Companies in the past 5 years?   Yes     No
     If Yes, please attach an explanation including the Insurance Company and premium volume per year.
9.  List insurance carriers with whom contracts have been terminated in the last five years and with whom 25% or
   more or your annual premium was placed (attach an explanation for each termination):
   
10.  Breakdown of Premium Volume by Line of Coverage:
  Personal Lines           Volume
   Automobile - Standard  
   Automobile - Non-standard (including Assigned Risk, JUA's, etc.)  
   Homeowners - Standard  
   Homeowners - Non-standard (including Fair Plans)  
   List other Personal Lines by Line:  
   1.   
   2.   
  TOTAL PERSONAL LINES:   
 
  Commercial Lines           Volume
   Workers Compensation  
   Commercial Auto  
   Commercial Multi-Peril  
   Inland Marine  
   Ocean/Wet Marine  
   Other Commercial Property  
   Bonds-Surety  
   Bonds-All Other  
   Aviation  
   Umbrella/Excess  
   Physicians & Hospitals  
   Professional Liability  
   Trusts including Workers Compensation Trusts, MET's, MEWA's, etc.  
   Risk Retention Plans  
   Other (Describe):   
  TOTAL COMMERCIAL LINES:   
   Life, Accident, Health  
  TOTAL ALL LINES   
11.  What percentage of the premium volume in question 10 is written on a non-admitted basis?   %
   (Do not include Assigned Risk, JUA's and Fair Plans).
12.  Office Loss Control Procedures:  
   Is all incoming mail date-stamped?    Yes     No
   Is a policy expiration list maintained with a suspense/diary system?    Yes     No
   Are all Applications, policies and endorsements checked prior to mailing or submission?    Yes     No
   Does the agency use a computerized agency management system?    Yes     No
   Identify System: 
   Number of Agents/Brokers with a CPCU or CLU Designation: 
Part III - Claim Information
Do not complete this section if this is an application for a renewal policy at the same limits of liability with one of the USLI Companies.
 
13.  During the past five (5) years, has any claim been made or suit brought against the agnecy, its predecessor(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)
14.  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 predecessor(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)
Part IV - Insurance Coverage Information
15.  Has any prospective insured ever had their license revoked or suspended or been fined or disciplined in any way
   by any state insurance department?   Yes     No    (If yes, please attach an explanation).
16.  Has any policy of or application for similar insurance on your behalf, or on the behalf of any of your principals,
   officers, employees, or on behalf of any of your predecessor(s) in business ever been declined, canceled, or
   renewal refused?   Yes     No    (If yes, please attach an explanation).
17.  Please provide the following information on your professional liability insurance for the past three years:
  Insurer Limit Deductible Policy Period Premium
 
 
 
18.  Retroactive Date of current policy (if any): 
19.  Have you ever purchased "Extended Discovery/Reporting Period" coverage ("tail") from any prior insurer?
     Yes     No    (If yes, please attach an explanation).
 
FRAUD STATEMENT: 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue or incomplete any statement made will immediately be reported in writing to the Insurer and the Insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Insurer is hereby authorized, but not required to make an investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the insurer and shall not stop the Insurer from relying on any statement in this Application. The signing of this Application does not bind the undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is understood the Insurer is relying on this Application in the event the policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become part of this policy.
 
 
Signature of Applicant or Insured:  _______________________________________________________
  Must be a Principal, Partner or Officer of the Firm
 
Date:  _______________________________________________________

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