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PART I - AGENCY DETAILS 2. a. Does (RT Specialty)

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PART I - AGENCY DETAILS
1. Agency Name:_______________________________________________________________________________________
Home Office Address _________________________________________________________________________________
City _____________________________________________ State __________________ Zip Code _____________
Phone ___________________________ Fax _________________________ Website _______________________
2. a. Does the applicant have any branch offices or subsidiaries? Yes No (If yes, please attach
an explanation.)
b. Is the applicant firm controlled, owned, affiliated or associated with any other firm, corporation or company?
Yes No (If yes, please attach an explanation.)
c. During the past 5 years has the name of the firm been changed or has any other business been acquired, merged into,
or consolidated with the original firm? Yes No (If yes, please attach an explanation.)
3. Date Established _____________________
(If less than three years in operation, also please attach resumes of key personnel.)
a. If applicable, date Applicant was first licensed as a Property/Casualty Agent or Broker _____________________
Number of years of experience as a licensed Property/Casualty Agent or Broker _____________________
b. If applicable, date Applicant was first licensed as a Life/Health Agent or Broker _____________________
Number of years of experience as a licensed Life Insurance Agent or Broker _____________________
Number of years of experience as a licensed Health Insurance Agent or Broker _____________________
4. Total number of personnel for each category:
Full Time Part Time
____________ ____________Licensed Agents and Brokers (employees & principals)
____________ ____________Licensed Agents and Brokers (independent contractors)
____________ ____________Clerical
____________ ____________Other (please specify ___________________________)
PART II - AGENCY OPERATIONS
5. Please give the approximate percentage breakdown of the total of your premium volume and fees as:
“Retail Agent” ______% (Business placed directly with insurance companies, JUA's or assigned risk pools, etc.)
“Retail Broker” ______% (Business placed through other agents, MGA's, wholesalers, etc.)
“Wholesale Broker” ______% (Business received from other non-employee or contract brokers or agents and placed by
your agency.)
“Other” (explain) ______% _________________________________________________________________________
Must total I00%
6. Do you derive income from any activity/profession other than the sale of insurance products? Yes No
(If yes, please attach an explanation including the percentage of your total annual income derived from it.)
7. Do you currently act or have you acted in the past five years as an MGA, Third Party Administrator, Reinsurance
Intermediary, or provided services for a fee as a Risk Manager/Consultant? Yes No
(If yes, please attach an explanation including the percentage of your total annual premium volume derived from it.)
PART III - PREMIUM VOLUME INFORMATION
8. List ALL Insurance Companies with which your Agency places business: (Use attachment if necessary.)
Total Annual
Insurance Company Direct Placement? Premium Volume AM Best Rating Admitted Carrier
___________________________ Yes No ______________ _____________ Yes No
___________________________ Yes No ______________ _____________ Yes No
___________________________ Yes No ______________ _____________ Yes No
___________________________ Yes No ______________ _____________ Yes No
___________________________ Yes No ______________ _____________ Yes No
9. Are there any insurance carriers with which agency contracts have been terminated in the last 5 years and with which 25%
or more of your annual premium was placed. Yes No (If Yes, attach an explanation for each termination.)
IAAPP (11/03) Page 1 of 3
Submit Application
10. Breakdown of annual written premium volume by line of coverage, and gross receipts if applicable as of this
date ________/ _______/ _______.
By signing this application, the Applicant represents that the written premium figures, and gross receipts if
applicable provided in question 10 are an accurate reflection of written premium at the time of signing the
application. The Applicant further agrees to provide, at the Company's request, full disclosure of the agency's books
and records for premium audit purposes. If an audit reveals a material change in premium than stated on the
application, then the company is entitled to collect additional earned premiums, cancel or rescind coverage.
ONLY ANSWER QUESTIONS #11-14 IF VOLUME IS LISTED UNDER QUESTION #10c (LIFE/ACCIDENT/HEALTH LINES).
11. How many times in the past 12 months have you replaced an existing Life Insurance policy with a new policy? _________
Why were these policies replaced? ______________________________________________________________________
12. Is applicant involved in the ownership, formulation, creation, administration, or operation of any self-insurance fund or pro-
gram, Multiple Employer Trust, Multiple Employer Welfare Arrangement, pool, syndicate, association or other combination
formed for the purpose of providing insurance or benefits when they are not fully funded by an insurance product?
Yes No If Yes, advise details ______________________________________________________________
13. If you place or service any Group Life, Accident or Health insurance, what is the largest plan (based on number of
participants) that you handle? __________________________________________________________________________
14. Is the applicant a captive agent? Yes No
Is applicant employed by any insurance company? Yes No If yes to either, please answer the following.
a. Please list the name of this company: ________________________________________________________________
b. Is professional liability already provided for business placed with this company? Yes No
ONLY ANSWER QUESTIONS #15-18 IF INCOME IS LISTED UNDER QUESTION #10d (INVESTMENT INCOME).
15. Do you have discretionary control of any clients' assets? Yes No
If yes, indicate the number of clients and the value of assets controlled: _________________________________________
16. Are you involved in the sale of structured settlement annuities? Yes No
17. Do you have any involvement in the development or solicitation of general or limited partnerships? Yes No
If yes, provide full details: _____________________________________________________________________________
18. What percentage of the premium volume listed in question 10 is written on a non-admitted basis? ____________________
(Do not include Assigned Risk, JUA'S, and Fair Plans)
IAAPP (11/03) Page 2 of 3
10a. PERSONAL LINES: Volume
Automobile - Standard . . . . . . . . . . . . . . . $ _________
Automobile - Non-standard (including
Assigned Risk, JUA'S, etc.) . . . . . . . . . . . $ _________
Homeowners - Standard . . . . . . . . . . . . . . $ _________
Homeowners - Non-standard
(including Fair Plans) . . . . . . . . . . . . . . . . $ _________
Personal Umbrella . . . . . . . . . . . . . . . . . . $ _________
Other (describe):. . . . . . . . . . . . . . . . . . . . $ _________
TOTAL PERSONAL LINES . . . . . . . . . . . . $ _________
10b. COMMERCIAL LINES:
Workers Compensation. . . . . . . . . . . . . . . $ _________
Long Haul Trucking. . . . . . . . . . . . . . . . . . $ _________
Commercial Auto (including Livery) . . . . . . $ _________
Commercial General Liability. . . . . . . . . . . $ _________
BOP (Businessowners policy) . . . . . . . . . . $ _________
Commercial Property . . . . . . . . . . . . . . . . $ _________
Ocean/Wet Marine . . . . . . . . . . . . . . . . . . $ _________
Inland Marine . . . . . . . . . . . . . . . . . . . . . . $ _________
Bonds. . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Aviation . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Commercial Umbrella / Excess . . . . . . . . . $ _________
Physicians & Hospitals . . . . . . . . . . . . . . . $ _________
Professional Liability . . . . . . . . . . . . . . . . . $ _________
Trusts including Workers Compensation
Trusts, MET's, MEWA's, etc . . . . . . . . . . . $ _________
Risk Retention Plans. . . . . . . . . . . . . . . . . $ _________
Crop / Hail . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Other (Describe) . . . . . . . . . . . . . . . . . . . $ _________
TOTAL COMMERCIAL LINES. . . . . . . . . . $ _________
10c. LIFE/ACCIDENT/HEALTH LINES:
Life, Individual. . . . . . . . . . . . . . . . . . . . . . $ _________
Life, Group . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Accident, Disability & Health, Individual . . . $ _________
Accident, Disability & Health, Group . . . . . $ _________
TOTAL LIFE/ACCIDENT/HEALTH LINES . $ _________
TOTAL ALL LINES. . . . . . . . . . . . . . . . . . $ _________
10d. INVESTMENT INCOME
List total gross receipts for the past twelve months for
the following activities:
Fixed Annuities . . . . . . . . . . . . . . . . . . . . . $ _________
Variable Annuities . . . . . . . . . . . . . . . . . . . $ _________
Mutual Funds . . . . . . . . . . . . . . . . . . . . . . $ _________
Stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Bonds. . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
Commodities. . . . . . . . . . . . . . . . . . . . . . . $ _________
Financial Plans for a Fee . . . . . . . . . . . . . $ _________
19. a Does the Total Insured Value of any Commercial Property or Inland Marine account written by the applicant exceed
one million dollars ($1 million)? Yes No (If yes, please attach a list of accounts including the
total insured value.)
b Do any classes of business account for over 10% of the applicant's commercial premium volume?
Bars/ Taverns/ Restaurants Yes No
Contractors Yes No
Other (please specify) Yes No ________________________________________________
PART IV - CLAIM INFORMATION
Do not complete this section if this is an application for a renewal policy at the same limit of liability with one of the USLI Companies.
20. During the past five (5) years, has any claim been made or suit brought against the agency, its predecessor(s) in business,
or any of its present or former owners, partners, officers, directors, employees, or independent contractors?
Yes No (If yes, provide details on the separate supplemental claims application.)
21. Is any owner, partner, officer, director, employee, or independent contractor aware of any circumstance, allegation,
contention, or incident which may result in a claim being made against the agency, its predecessor(s) in business, or any of
its present or former owners, partners, officers, directors, employees, or independent contractors? Yes No
(If yes, provide details on the separate supplemental claims application.)
PART V - INSURANCE COVERAGE INFORMATION
22. Has any prospective insured ever had their license revoked or suspended or been fined or disciplined in any way or been
the subject of any investigation by any state insurance department? Yes No (If yes, please attach
an explanation.)
23. During the past five years, has any director, officer, partner, employee, or independent contractor ever been declined,
cancelled or refused renewal of their fidelity or surety bond? Yes No
If yes, provide full details: _____________________________________________________________________________
__________________________________________________________________________________________________
24. Has any policy of or application for similar insurance on your behalf or on the behalf of any of your principals, officers,
employees, or on behalf of any predecessors in business ever been declined, canceled, or renewal refused?
Yes No (If yes, please attach an explanation.)
25. Please provide the following information on your professional liability insurance for the past three years:
Name of Insurer Limit Deductible Policy Period Premium
________________________________ _____________ _____________ _____________ ____________
________________________________ _____________ _____________ _____________ ____________
________________________________ _____________ _____________ _____________ ____________
26. Retroactive Date of current policy (if any): _____/ _____/ _____
27. Have you ever purchased "Extended Discovery/Reporting Period" coverage ("tail") from any prior insurer?
Yes No (If yes, please attach an explanation.)
IAAPP (11/03) Page 3 of 3
FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true, The
undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for
which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Insurer
and the Insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance.
The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information,
statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or
inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement
in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a
policy be issued and it will be attached and become a part of the policy.
Signature of Applicant or Insured: _______________________________________________________________________
Must be signed by a Principal, Partner or Officer of the Firm
Date:________________________________________________________________________________________________
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PART I - AGENCY DETAILS 2. a. Does (RT Specialty)

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Completed 13 December 2020

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