Fillable Advertising Agency Application (Kinsale Insurance)

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Advertising Agency Application (Kinsale Insurance)

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The Advertising Agency Application (Kinsale Insurance) form is 4 pages long and contains:

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  • 41 check-boxes
  • 78 other fields

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Page 1 of 4
ADVERTISING AGENCY/COMMUNICATIONS LIABILITY
ERRORS
& OMISSIONS APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
____________________
6. County of primary location: Date business originally established: __________________________
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
_______
9. What is your phone number?
__________________________________________________
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased,
merged or consolidated with you? Yes No
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Number of years operated under present ownership? Annual Revenues $
2. Coverage requested: Limit of liability Retention
(If additional space is needed, please give details on a separate page.)
3. a. Gross billings $
Fees $
Total $
b. Percentage of gross billings in the following media:
Magazine
______% Newspapers ______% Outdoor _____% Radio ______% Television ___
% Other _____%
APPLICANT’S INFORMATION
GENERAL INFORMATION
BUSINESS OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
c. Percentage of work in the following areas:
Broadcasting % Production of film, TV or radio programs %
Mail order/catalogs % Public relations %
Package design % Publishing %
Photography % Other (describe) %
4. Do you specialize in certain kinds of advertising or marketing services? Yes No
If Yes, please describe specialization:
5. Do you engage in advertising activities outside of the United States, its territories and Yes No
possessions or Canada?
If Yes, what is the amount of foreign: Gross Billings $ Fees $
6. Do you obtain written releases with respect to creative material or talent from:
a. Employees Yes No
b. Models Yes No
c. Freelancers, photographers, writers, composers, artists, illustrators or musician Yes No
d. Non-professional persons appearing in commercials or advertisements Yes No
7. Do you engage in comparative advertising campaigns?
If Yes, provide name of client and description of the campaign.
8. Name of advertising associations or trade groups to which you belong:
9. a. Name and address of attorney and law firm which counsels for controversial material, detamation, copyright, etc.
b. Name of in-house counsel:
c. Does law firm or in-house counsel review controversial material? Yes No
d. Years of experience in libel law: Law Firm years/In-house counsel years
10. Have you been cited by an government agency for violations arising out of your advertising Yes No
activities?
If Yes, provide complete details:
11. In the last ten years, has the applicant been sued or threatened with suits for libel, slander, invasion Yes No
of privacy, piracy, plagiarism, infringement of copyright or errors or omissions?
If Yes, attach details of each claim to include amount of plea, judgment or settlement, basis of claim, current status and
amount of reserve and legal expenses to date.
CHECK YOUR PROPOSAL TO DETERMINE IF OPTIONAL COVERAGE(S) APPLY.
12. a. Do you desire coverage for trademark, trade name, service mark or service name? Yes No
If Yes, describe clearance procedures:
b. Do you desire coverage for errors and omissions for claims arising from the content of matter Yes No
in advertising?
RISK MANAGEMENT PROCEDURES AND CLAIM INFORMATION
OPTIONAL COVERAGES
Page 3 of 4
13. Prior insurance (last three years):
Policy Period Carrier Policy No. Limit of Liability Retention Premium
14. Has any insurer declined, cancelled or non-renewed similar insurance for which you are applying? Yes No
If yes, provide details.
15. Do you maintain comprehensive general liability insurance? Yes No
Carrier Policy Period
Policy No. Limit of Liability
Personal injury coverage is: Included Excluded
16. TO COMPLETE YOUR APPLICATION, PLEASE ATTACH:
a. Promotional materials/brochures describing your services.
b. Specimen client contract.
c. Specimen creative release forms.
d. List of major clients and description of their products or services.
e. Current financial statement.
f. Experience resume of management (if ownership is less than three years).
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for 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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of 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 KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly 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 MAINE 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 may include imprisonment, fines, or denial of insurance benefits.
INSURANCE INFORMATION
Page 4 of 4
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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.
NOTICE TO VIRGINIA 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Advertising Agency Application (Kinsale Insurance)

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Completed 15 July 2020

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