Fillable MGA Supplemental Application

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MGA Supplemental Application

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The MGA Supplemental Application form is 3 pages long and contains:

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  • 15 check-boxes
  • 59 other fields

Country of origin: US
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Page 1 of 3
MANAGING GENERAL AGENTS SUPPLEMENTAL APPLICATION
(To Be Submitted with the Kinsale Insurance Agents and Brokers Errors and 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 any names of other entities that you own or manage or that you do business under:
____________________
_________________________________________________________________________________________________
3. Primary Location Address:
4. Applicant Address: Same as above
5. List all addresses for other offices:
1. Provide the following information for each organization that the Applicant has represented as an MGA, Underwriting
Manager or Program Administrator for the last five years.
Insurer
Domicile of Insurer
Number of Years
Represented
Annual Premium
Volume
Number of Times
Audited per Year
2. Please fully describe your responsibilities/duties as an MGA, Underwriting Manager or Program Administrator. (Attach
additional pages if more space is needed.)
APPLICANT’S INFORMATION
MANAGING GENERAL AGENTS, UNDERWRITING MANAGERS AND PROGRAM ADMINISTRATORS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 3
3. In the last three years has any audit by an insurer stated that the Applicant:
(a) Had exceeded its premium cap or underwriting authority? Yes No
(b) Did not issue the correct policy wording and/or endorsements as mandated by the insurer? Yes No
(c) If Yes to either of the above questions, provide details and actions taken to amend procedures.
______________
4. In the last three years, other than minor infractions, were all audits by insurers satisfactory? Yes No
If No, provide details.
___________
_______________
5. In the last five years has any:
(a) MGA, Underwriting Manager or Program Administrator contract authority been canceled,
revoked or terminated? Yes No
(b) Insurer added any restrictions to the Applicant's underwriting or claim handling authority? Yes No
(c) If Yes to either of the above questions, provide details.
________
6. (a) What is the Applicant's maximum authority for the following:
Binding Risks $
Claims Adjusting/Administration $
Loss Control $
Reinsurance Placement $
(b) Does the Applicant have authority for any insurer other than stated in 1. herein above? Yes No
If Yes, provide details.
(c) Total number of insurers for which the Applicant has authority of any kind:
__________________________________________________________________________
7. (a) Provide the total number of producers that the Applicant has appointed as sub agents.
(b) Has the Applicant delegated any underwriting, claim handling and/or any other authority to any Yes No
sub agent?
If Yes:
(i) Provide a detailed description.
(ii) Provide a copy of the contract with the insurer that authorizes the Applicant to delegate authority to other
organizations.
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.
Page 3 of 3
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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MGA Supplemental Application

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Completed 2 July 2020

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