Fillable Collection Agency Application

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Collection Agency Application

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Page 1 of 5
COLLECTION AGENCY
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, merged or consolidated
with the entity within the last 5 years? Yes
No
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. A. Year Established
_____________________
B. Individually Owned Partnership Corporation
Number of Locations
2. Full & complete description of operations/services.
(Also attach a copy of the firm’s brochures)
3. Indicate the specific types of claims or exposures for which coverage is desired.
4. What safeguards or procedures does the firm employ to avoid or reduce the claims and/or exposures identified in
question #3 above?
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
5. Attach a listing, on the firm’s stationary, of the firm’s five largest projects during the past five years. Include the client
Name, description of services rendered and fees generated from each.
6. A. Has the name or ownership of the firm changed or has any other business been Yes No
purchased, merged or consolidated with the firm within the last 5 years?
B. Is the firm owned or controlled by any other firm or individual? Yes No
C. Does the firm, or any owner or officer of the firm own, engage in, operate, manage or Yes No
act as a director or officer of any other business?
D. Has any license held by the firm or any individual ever been suspended or revoked? Yes No
E. Have any persons proposed for this coverage ever been subject to disciplinary action Yes No
by any state licensing board, court, regulatory authority, or professional association as
a result of professional activities?
7. Is the firm or any partner, shareholder, principal or employee bonded for handling client funds? Yes No
8. Within the past five years, has the firm performed any professional services for any client in which any shareholder,
officer or employee of the firm had any ownership interest, or which he/she controlled, operated or managed to any
extent?
Client Name Type of Business Ownership % Capacity Engagement Annual Fees
9. Within the past five years, has the firm or any partner, officer, principal or employee had any application for
professional liability insurance denied, or policy cancelled or non-renewed? Yes No
If “Yes,” please provide an explanation:
10. Has the firm or any past or present owner, partner, shareholder, principal, officer, director or employee ever
been subject to disciplinary action by a state licensing agency or other regulatory body? Yes No
If “Yes,” please provide an explanation:
11. Have any claims (including lawsuits) been made against the firm, its predecessors, or past or present owners,
directors, officers, employees or other individuals during the past five years? Yes No
If “Yes,” please complete a separate Supplemental Claim Form for each claim or suit.
12. Is the firm aware of any circumstances or any allegations or contentions, which may result in a claim (including
lawsuits) being made against the firm, its predecessors, or past or present owners, directors, officers or other
individuals? Yes No
If “Yes,” please complete a separate Supplemental Claim Form for each incident.
13. A. Total Gross Fees: Last Year $___________________ This Year (est) $________________________
B. Total Payroll: Last Year $_____________________ This Year (est) $________________________
C. Does any single client provide over 30% of gross receipts? Yes No
If “Yes,” please provide details: ___
14. What percentage of applicant’s business involves subcontracting work to others? __________%
Cost of subcontracted work ___________________What operations are subcontracted?
Page 3 of 5
15. Individuals – Please list all owner(s), partners, officers, and employees engaged in professional services. Include
part- time employees and all professional staff members. Continue in question 30 if necessary.
Name Title Years in Practice
16. Education, Training, Management:
A. Please attach a resume for each owner, partner, principal and professional/technical employee.
B. Do all employees (including management) attend at least one annual educational seminar? Yes No
C. Is educational material presented to, and reviewed with, all employees at least semi-annually? Yes No
D. What percentage of employees have less than 2 years business related experience?
E. Is management active in daily operations? Yes No
%
Please, enclose any disclaimers and/or descriptive brochures which are provided to existing or prospective clients.
17. Membership(s) in Professional Organizations, Associations and Societies: Yes No
Name(s) of organization(s)
18. Does the Applicant collect funds for others for a fee? Yes No
If “Yes,” provide the type of debt and the average size of debt collected:
19. Provide the percentage of the procedures used to collect funds:
(i) Letters %
(ii) Telephone calls %
(iii) Personal contact %
(iv) Institution of legal proceedings %
(v) Other (please describe below) %
20. Is the Applicant agency bonded? Yes No
If “Yes,” provide the following:
Fidelity Bond: Carrier Expiration Date Amount
Surety Bond: Carrier Expiration date Amount
21. List all states where you pursue collection monies:
22. Describe all steps taken to comply with the FDCPA and all applicable state collection laws:
23. Does the Applicant have any attorneys on staff? Yes No
If “Yes,” how many?
24. Describe fully the extent of litigation activities/involvement with your collection agency:
Page 4 of 5
25. Has a lawyer reviewed & approved all collection forms/letters that are sent: Yes No
If “No” to the above, please explain why not:
26. Describe fully the extent of involvement with repossessing property of others:
27. As part of this Supplement attach copies of the Applicant’s collection letters, demand forms and collection telephone
scripts.
28. Errors and Omissions coverage provided to the firm for the past five years:
From/To Carrier Limit Deductible Premiums Retroactive Date
29. Coverage Requested:
Requested Effective Date
Requested Retroactive Date
(If prior acts coverage is desired, a copy of current policy declarations must be attached.)
Limits of Liability: $100,000/$100,000 $300,000/$300,000 $500,000/$500,000
$1,000,000/$1,000,000
Deductible: $1,500 $2,500 $5,000 $10,000
30. Supplemental Information (Use this area to provide additional information)
Question # Additional Information
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.
Page 5 of 5
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.
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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Collection Agency Application

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Completed 2 July 2020

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