Fillable Insurance Agents Renewal Application 310002-P (4/97) page 1 of 11

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Insurance Agents Renewal Application 310002-P (4/97) page 1 of 11

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Page 1 of 4
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
INSURANCE AGENTS AND BROKERS
RENEWAL APPLICATION
ERRORS & OMISSIONS APPLICATION
1. Current Kinsale policy number:
2. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
3. Please list all other business/dba names for which you are seeking coverage under this policy:
_________________________________________________________________________________________________
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. 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 past 12 months or are any such changes
contemplated in the next 12 months?
If “Yes”, please provide a description of the changes on an attached sheet of paper.
1. List all the Applicant firm’s personnel:
(Each individual should be classified in only one category.)
Owners, Officers, Partner Exclusive Non-employee Producers
Employee Solicitors, Brokers, Agents Non-exclusive Producers
Other employees (including clerical) TOTAL STAFF (including part time)
2. Please provide your agency’s projections for annual premium volume, commission income, policy count, and revenue
generated from “other” income not including commission income for the next 12 months:
Annual Premiums Annual Commission
Income
Policy Count Annual “Other”
Income
Most recent 12 months
Previous 12 months
Projected next 12 months
3. List the 5 insurance companies for whom applicant firm places the most annual premium.
Name of
Insurance
Company
% of Total
Premium
Volume
A.M. Best
Rating
Years
Represented
Major Lines
Placed
Binding
Authority?
Yes or No?
If binding
authority, what
line of business?
APPLICANT’S INFORMATION
GENERAL INFORMATION
Page 2 of 4
4. Approximate percentage of the total annual volume you do as:
1. Agent
____
Broker
% 2. Retailer or Business direct from other agents %
____
Managing General
% Wholesale or Business accepted from other agents %
____% * Must Total 100%
Surplus Lines Broker
____
Consultant (for fee)
%
____
Other (specify)
%
____
Must Total
%
100%
5. Using projections for the next 12 months, please categorize your total annual premium volume by line of business:
A C
%
Personal Lines Home/Auto-Standard %
Accident, Life & Health-Group
%
%
Subtotal (A) Accident, Life & Health-Individual
B %
Aviation
%
Auto-Commercial (except long haul trucking) %
Crop
%
Bonds %
Long Haul or Intermediate Trucking
%
Commercial-General Liability %
Marine-Ocean or other “wet” marine
%
Commercial-Property %
Physicians/Hospitals
%
Marine-Inland
%
Professional Liability/D&O
%
Personal Lines Home/Auto-Sub-Standard
%
Other (explain)
%
Workers Compensation
%
Subtotal (B) %
Subtotal (C)
100%
Total A + B + C
1. Do you confirm to the Insured, in writing, all declinations of coverage? Yes No
2. Do you confirm, in writing, an insured’s rejection of increased uninsured motorist or Yes No
underinsured motorist limits 100% of the time? If “no”, why not?
3. Is applicant involved in handling any stranger-originated life insurance policies? Yes No
If “yes”, please give the percentage of stranger-originated policies handled.
%
4. In the past 12 months, has any carrier (or other risk bearing entity) with which your agency has placed Yes No
business become insolvent, bankrupt, put into rehabilitation/receivership, or otherwise become
unable to meet its duties to insureds?
If “yes”, please explain including the name of the entity, dates involved, lines of business placed,
and premium volume involved:
5. Has any contract for this agency been withdrawn by a carrier in the last 12 months for any reason Yes No
other than lack of production?
If “yes”, please explain:
RISK MANAGEMENT
*if any value is present, fill out MGA Supplemental form
Page 3 of 4
1. After inquiry with each person as appropriate, during the last 12 months, have any claims Yes No
been made against the person or entity applying for insurance, or any of your past or
present members, partners, officers, directors, employees, or any predecessors in business?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
2. After inquiry with each person as appropriate, have any new claims/incidents/circumstances Yes No
been reported to any previous carrier including under an extended reporting period?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
3. Please provide details of any status changes in previously reported claims including changes in
amounts paid in defense costs or to settle claims.
Please include an updated loss run for any previously reported unresolved claims.
4. After inquiry with each person as appropriate, are you, or any of your partners, officers, Yes No
directors, or employees, aware of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident which may result in a claim?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
5. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, Yes No
or employees been the subject of any complaint or subject to any disciplinary action by any state
licensing agency or other regulatory body during the last 12 months?
If “yes”, please provide an explanation of the circumstances and penalty involved. If available,
please provide a copy of the complaint, your response, and a copy of the regulatory body’s decision.
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.
INSURANCE AND LOSS HISTORY
Page 4 of 4
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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Completed 2 July 2020

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