Fill - Free fillable Insurance Agents & Brokers Professional Liability Application NOTICE: (All Risks, Ltd) PDF form

ARL EO 001 011121 Page 1 of 8

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National Specialty Programs

Toll-Free: 800-366-5810 • Fax: 410-828-8179

Insurance Agents & Brokers Professional Liability Application

NOTICE: THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THIS POLICY WILL

APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSUREDS AND REPORTED TO THE INSURER DURING THE POLICY

PERIOD OR ANY EXTENDED REPORTING PERIOD THAT MAY APPLY. PLEASE READ THE POLICY CAREFULLY TO DETERMINE

RIGHTS, DUTIES, COVERAGE AND COVERAGE RESTRICTIONS.

Whenever used in this Application, the term Applicant shall mean the Named Insured proposed for insurance, and You or

Your(s) shall mean the persons and entities, including subsidiaries, proposed for insurance, unless otherwise stated.

1. Name of Applicant (include all DBAs): ___________________________________________________________________

____________________________________________________________________________________________________

Primary Physical Address: ______________________________________________________________________________

Mailing Address (if different): ___________________________________________________________________________

Are there any branch offices? Yes No

If yes, how many? ___________ In what states? _______________________________________________

Contact Name: ________________________________________ Title: ____________________________________

Phone: ______________________ Fax: ______________________

Email: _________________________________________ Website: _______________________________________

2. Ownership:

A. Are you owned or controlled by, or affiliated with any other firm? Yes No

If yes, please attach details.

B. Have you purchased, merged or been consolidated with any other firm in the past 3 years? Yes No

If yes, please attach details.

C. Do you have subsidiaries? Yes No

If yes, list their names, type of operation, and whether or not you wish to apply for coverage for them (use a

separate sheet if necessary):

Name of Subsidiary

Type of Operation

Applying for Coverage

Yes No

3. Date your firm was established: _________________ (If less than 3 full years, attach a résumé of all principals with prior

agency/brokerage management experience.)

4. List the percentage of your business derived from your activities in each role (total must equal 100%):

Agent/Broker: _______% Reinsurance Broker/Intermediary: _______%

*MGA/MGU/General Agent/Program Administrator: _______% Wholesaler: _______%

Other: _______% (Specify): __________________

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*If you are in whole or in part an MGA, MGU, General Agent and/or Program Administrator, please complete the

MGA/GENERAL AGENT/PROGRAM ADMINISTRATOR Supplemental Application.

5. Staffing:

A. Indicate your total agency headcount (including self): ________

B. Of these, indicate how many are:

a. Licensed Agent or Broker FT: ________ PT: ________

b. 1099 Agent/Independent Contractor FT: ________ PT: ________

c. Other Management Professional FT: ________ PT: ________

d. Administrative/Other: FT: ________ PT: ________

C. List the names of all partners, principals and key employees below (please include yourself):

Name

Yrs in Insurance

Yrs Licensed

Yrs with Applicant

Professional Designations

D. During the past 5 years, have there been any changes in management structure, including any additions or

deletions of any principals, owners or managers? Yes No

If yes, provide details: ___________________________________________________________________________

E. Are you a member of any cluster arrangements? Yes No

If yes, provide details: ___________________________________________________________________________

F. What percentage of your licensed staff hold designations? (CPCU, RPLU, etc.): _______%

6. Revenues:

A. Indicate your premium volume and gross insurance commissions and fees (before split with others) for the past

2 years and an estimate for the current year:

Year

P&C Premium

Life/A&H Premium

Gross P&C Commissions/Fees

Gross Life/A&H Commissions/Fees

B. Do you anticipate any significant changes in the nature of your operation, or changes of 25% or more

in the size of your operations, over the next 24 months? Yes No

If yes, please attach details.

C. Do you anticipate writing any new lines of coverage in the next 12 months? Yes No

If yes, provide details: ___________________________________________________________________________

7. Indicate and describe your non-insurance business revenues for the past 2 years:

Year

Non-Insurance Revenue

Sources

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8. List your top five (5) A.M. Best rated insurers who have a rating of B+ or better:

Insurer

Annual

Premium

Volume

Years

Represented

Do you have

Underwriting

Authority?

Line of Business

A.M. Best Rating

Yes No

9. List all markets where you have placed business in the past 2 years that are rated below B+ by A.M. Best, non-rated, or

self insured plans. Use additional sheets if necessary:

Insurer

Annual

Premium

Volume

Years

Represented

Do you have

Underwriting

Authority?

Line of Business

A.M. Best Rating

(if applicable)

Yes No

10. List your three (3) largest commercial clients together with the services provided and revenues derived from each:

Client

Services You Provide

Your Revenue

11. Indicate the percentage of your total premium volume (Total of all lines of business must equal 100%. Please note

the lines of business are continued on page 4.):

Personal Lines:

Homeowners: _______%

Marine: _______%

Non-Standard Auto: _______%

Standard Auto: _______%

Umbrella: _______%

Other (Specify): _________ _______%

Commercial Lines:

Auto (except Long Haul Trucking: _______%

Aviation: _______%

Commercial Package (BOP/SMP): _______%

Commercial Property: _______%

Crop: _______%

Fidelity: _______%

GL/Products: _______%

Inland Marine: _______%

Long Haul Trucking: _______%

Medical Malpractice: _______%

Ocean Marine: _______%

Professional Liability/D&O: _______%

Surety: _______%

WC (Non-retro): _______%

WC (Retro): _______%

Other (Specify): _________ _______%

Group Life/Accident & Health:

Dental: _______%

Fully Insured Health: _______%

Self-Insured Health: _______%

Life: _______%

LTD: _______%

METS/MEWAS: _______%

STD: _______%

Stop Loss: _______%

Other (Specify): _________ _______%

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Individual Life/Accident & Health:

Accident/AD&D: _______%

COLI/BOLI: _______%

Credit Life: _______%

Fixed Annuities: _______%

Health: _______%

LTC: _______%

LTD: _______%

Premium Financed Life: _______%

STD: _______%

Split Dollar: _______%

Term Life: _______%

Universal Life: _______%

Whole Life: _______%

Other (Specify): _________ _______%

12. Have you placed crop or aviation insurance at any point in the last 5 years? Yes No

13. Percentage of business placed on a surplus lines basis: _______%

14. Provide a breakdown of client industries served for Commercial Property & Casualty placement only. N/A

Construction: _______%

Government: _______%

Hospitality: _______%

Insurance: _______%

Legal: _______%

Manufacturing: _______%

Medical/Hospital: _______%

Technology: _______%

Transportation: _______%

Warehouse: _______%

All Other: _______%

(Breakdown of Other): _____________________

15. Broker/Dealer Exposure:

A. Indicate your commissions derived from each of the following: N/A

401K Plans:_____________________

Mutual Funds:_____________________

Pension Plans:_____________________

Stocks and Bonds:_____________________

Variable Annuities:_____________________

Variable Life:_____________________

Yes No

B. Do you have coverage through the broker/dealer?

C. Have there been any U-4 or U-5 violations?

If yes, please attach details.

D. Do all agents placing the products in 15A have at least 3 years experience?

Yes No

16. Indicate if you provide the following services

A. Claims Adjusting Yes No

If yes, do you have the authority to deny claims? Yes No

B. Claims Draft Authority Yes No

If yes, indicate maximum amount: _____________________

C. Inspections, Safety Engineering, Loss Control or Risk Management Yes No

If yes, describe: ________________________________________________________________________________

D. TPA Services Yes No

E. Reinsurance Placement Yes No

F. Actuarial Service Yes No

G. Underwriting Yes No

If yes, please complete the MGA Supplemental Application.

17. Do you:

A. Have written standard operating procedures? Yes No

B. Date stamp all incoming mail? Yes No

C. Document client’s refusal to accept coverage or limit recommendations? Yes No

D. Have an approved list of carriers? Yes No

E. Confirm verbal binders in writing? Yes No

F. Appoint sub-agents? Yes No

G. Have written procedures for handling COIs? Yes No

H. Refer requests for non-standard language on COIs to the insurer? Yes No

I. Monitor carrier ratings and notify clients immediately if downgraded? Yes No

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18. Computer Systems:

A. Do you conduct background checks on employees who have access to sensitive

data and systems? Yes No

B. Do you restrict user rights on computer systems so that individuals and third-party service

providers only have access to those areas of the network or information that is necessary for

them to perform their duties? Yes No

C. Are you only using software applications and operating systems:

a. That are currently supported by their providers? Yes No

b. That have automatic updates turned on? Yes No

D. Do you have secure email practices such as automatically scanning and filtering emails? Yes No

E. Do you delete/destroy data stored on devices and media that are scheduled to be recycled,

sold or disposed? Yes No

F. Do you conduct computer and information security training for every employee who has

access to computer systems or sensitive data at least annually? Yes No

If yes, are they required to acknowledge their security responsibilities? Yes No

G. Have you installed or activated anti-virus software active on all computers and networks? Yes No

H. Do you have a written information security plan (WISP)? Yes No

I. Do you make backups of critical data and systems? Yes No

19. In the past 5 years, have you:

A. Discontinued any program or classes of business you are not currently involved with that

accounted for more than 10% of your volume? Yes No

B. Placed coverage with or referred clients to any Self Insured/Captive; Professional Employer

Organization (PEO); Multiple Employer Trust or Welfare Arrangement (MET or MEWA)? Yes No

C. Been involved in the establishment or management of any Risk Retention Group (RRG); Risk

Purchasing Group (RPG); Professional Employer Organization (PEO); Multiple Employer Trust or

Welfare Arrangement (MET or MEWA); Insurance Company (including, but not limited to, any

Captive) or any similar organization? Yes No

D. Been involved in any structured settlement, viatical settlement, or the placement of any

vanishing premium life insurance policy? Yes No

E. Been involved with the establishment or management of any fronted program? Yes No

If yes to any of the above, please attach an explanation including the name of the program(s), carrier(s), extent of

coverage(s) provided, and administrative duties performed.

20. Cancellation:

A. Have you had any agency contracts canceled by any insurance carrier for reasons other than lack of

production? Yes No

If yes, please attach details.

B. Has your Professional Liability insurance ever been declined or canceled? Yes No

If yes, please attach details.

21. Do you currently have Professional Liability insurance in force? Yes No

If yes, provide the following for your five most recent policies:

Expiration Date

Insurer

Limits of Liability

Deductible

Premium

Retroactive date or length of time that coverage has been continuously in force: _____________________

22. Are you appointed with Hanover Insurance or any other Hanover affiliated company? Yes No

NOTICE TO ARKANSAS, LOUISIANA AND WEST VIRGINIA 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.

ARL EO 001 011121 Page 6 of 8 RSGprograms.com

23. Limits of Liability Desired:

A. $________________ each wrongful act or series of continuous, repeated or interrelated wrongful acts

B. $________________aggregate

You may apply for defense costs to be in addition to or included within the above limits.

Indicate your preference: Defense costs to be in addition to the above limits? Yes No

C. Deductible Desired $1,000 $2,500 $5,000 $10,000 $25,000

Other ____________________

You may apply to have the deductible applied to damages only or to both damages and defense costs.

Indicate your preference: Deductible to apply to damages only? Yes No

24. During the past 5 years, has any Professional Liability claim or suit ever been made against the

Applicant, any predecessor firm or any of the Applicant’s current or former professional staff? Yes No

If yes, indicate how many: _______

Please submit five (5) year loss runs and complete a Supplemental Claim Form for each claim.

25. Does any of the Applicant’s professional staff know of any incident, negligent act, error or omission,

or other circumstances that could result in a claim or suit against the Applicant or any predecessor firm

or any of the Applicant’s current or former professional staff? Yes No

If yes, indicate how many: _______ and complete a separate Supplemental Claim Form for each potential claim.

26. Has any of the Applicant’s or a predecessor firm’s professional staff ever had their license revoked or

suspended or been formerly reprimanded or been the subject of a disciplinary action? Yes No

If yes, please provide complete details on a separate sheet

All written statements and materials furnished in conjunction with this application are hereby incorporated into this

application and made a part hereof.

PLEASE NOTE THE FOLLOWING: The undersigned, acting on behalf of the Applicants, represents that the statements set

forth in this Application are true and correct and that thorough efforts were made to obtain requested information from

all of You to facilitate the proper and accurate completion of this Application.

The undersigned agree that the information provided in this Application and any material submitted herewith are the

representations of all of You and that they are material and are the basis for issuance of the insurance Policy provided by

Us. The undersigned further agree that the Application and any material submitted herewith shall be considered attached

to and a part of the Policy. Any material submitted with the Application shall be maintained on file (either electronically or

paper) with Us.

It is further agreed that:

 If any of You discover or become aware of any material change which would render the Application inaccurate or

incomplete between the date of this application and the Policy inception date, notice of such change will be

reported in writing to Us as soon as practicable;

 Any Policy issued will be in reliance upon the truthfulness of the information provided in this Application.

 The signing of this Application does not bind the Applicant to purchase insurance.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a

loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may

be subject to restitution fines or confinement in prison, or any combination thereof.

NOTICE TO ARIZONA AND MISSOURI APPLICANTS: Claim Expenses are Inside the Policy Limits. All claim expenses shall

first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages.

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NOTICE TO CALIFORNIA APPLICANTS: For your protection, California law requires the following to appear on this form:

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be

subject to fines and confinement in state prison.

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 policyholder or

claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a

settlement or award payable from 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 insurer

files a statement of claim or an application 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 IDAHO AND OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or

deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or

misleading information is guilty of a felony.

NOTICE TO KANSAS APPLICANTS: Any person who commits a fraudulent insurance act is guilty of a crime and may be

subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any

person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or

belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written,

electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in

support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance,

or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which

such person knows to contain materially false information concerning any fact material thereto; or conceals, for the

purpose of misleading, information concerning any fact material thereto.

NOTICE TO KENTUCKY APPLICANTS: 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.

NOTICE TO MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON 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 MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for

payment of a loss or benefit or knowingly or willfully 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 MICHIGAN APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or

another 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 act, which is a crime and

subjects the person to criminal and civil penalties.

NOTICE TO NEW JERSEY APPLICANTS: Any person who knowingly includes any false or misleading information on an

application for an insurance policy or files a statement of claim containing any false or misleading information is subject

to criminal and civil penalties.

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NOTICE TO NEW HAMPSHIRE 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.

NOTICE TO NEW MEXICO AND RHODE ISLAND 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 OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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 OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud

any insurance company: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any

material fact, may be violating state law.

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 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 such person to criminal and civil penalties.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for

insurance may be guilty of a criminal offense and subject to penalties under state law.

This Application must be signed by a representative of the Applicant acting as the authorized representative of the

person(s) and entity(ies) proposed for this insurance.

Signature of Owner, Officer or Partner: _____________________________________________________

Name: __________________________________ Title: __________________________________

Date: ___________________________

RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a

subsidiary of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the

public. Some products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC

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