Fillable PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION (Risk Placement Services, Inc.)

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PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION (Risk Placement Services, Inc.)

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IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 1 of 6
May not be copied without permission.
COMPANY PROVIDING COVERAGE: Greenwich Insurance Company
Indian Harbor Insurance Company
PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS
APPLICATION
NOTICE
The Insurance coverage for which you are applying is written on a claims-made and reported policy form. Subject to
policy provisions, this insurance will apply only to claims that are first made against you and reported to the Company
while the policy is in force. This policy provides that the limits of liability available to pay judgments or settlements shall
be reduced by amounts incurred for legal defense. Further note that amounts incurred for legal defense shall be applied
against the deductible amount.
Please P
rint or Type and complete all questions.
1.
Name of
Agency:
Dba: (if
applicable)
Website:
Phone No.:
Fax No.:
Physical
Address:
City:
State:
County:
Zip Code:
2.
Additional Business Locations: (Attach a separate sheet, if necessary).
3.
YES
NO
N/A
(If NO, attach full details).
4.
What percent (%) of your business is:
Retail (Business sold directly to Insureds)
%
Wholesale (Business placed for other agents)*
%
MGA (Business for which you have underwriting authority)*
%
MUST TOTAL 100%
%
*indicates Supplemental Application must be completed
5.
Is the Agency a:
Corporation
Partnership
Sole Proprietorship
LLC
Other (specify)
Below list the names of officers/owners/principals/partners/members and years of insurance experience. (Attach another
sheet if necessary).
N
AME
R
ELATIONSHIP TO
A
GENCY
Y
EARS OF
E
XPERIENCE
6.
a.
Year Agency Established:
(If less than 3 years, attach resumes for all agency staff).
b.
Years managed by current ownership:
c.
Total staff size including Officers, Owners, Principals, CSR’s, etc.:
Full Time
Part time
Total non-employee 1099 producers:
Full Time
Part time
Number of employees with less than 3 years insurance experience:
d.
Turnover rate (%):
Sales/Marketing:
Licensed Service:
Other (Describe):
IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 2 of 6
May not be copied without permission.
15. Provide a breakdown of total annual agency income for each of the following:
Transacting business as:
% of income
Lines of Business or risk type:
% of income
Third Party Administrator
Personal Lines
Premium Finance Company
Individual Life Insurance
Reinsurance Intermediary
Group Life Insurance
Insurance Consultant
Individual Accident & Health
Group Accident & Health
Long Haul Trucking
Contract Surety Bonds
Environmental Liability
For Profit Directors & Officers Liability
Wet Marine (Commercial)
Crop Insurance
Aviation
E&O/Professional Liability (Describe)__________
Medical Malpractice
Restaurant/Tavern/Bar
Commercial Auto Fleets (+5 vehicles)
Vacant properties
7.
Is agency owned (any %), controlled by or associated with any other business entity of any kind?
YES
NO
(If yes, please provide details on separate sheet including the name of the entity and their nature of
business).
8.
Within the last five years have there been:
a.
Any name changes?
YES
NO
b.
Ownership changes?
YES
NO
c.
Mergers, acquisitions or purchase of any books of business, in part or whole?
YES
NO
(If you answered YES to any of Question 8, attach a detailed explanation).
9.
Please provide:
a.
Total last 12 months Gross Written Premium Volume:
$
___________________
b.
Total last 12 months Gross Written Premium Volume – Life & Health ONLY:
$
___________________
c.
Total last 12 months Gross Commission Income:
$
___________________
d.
Total Net Retained Commission Income (Wholesale Agents Only):
$
___________________
e.
Total income from OTHER INSURANCE RELATED ACTIVITIES (Describe):
$
___________________
10.
Estimate the amount of business the agency places with carriers Rated less than B+ or non-rated carriers.
%
What procedures do you have in place to advise the insured of the financial risk involved in placing business
with these insurers?
11.
Estimate the percentage of business which is direct billed by carriers:
12.
Estimate the % of your business, if any, which is serviced by insurance carrier Service Center staff.
13.
Show your five largest carriers/companies and the percent of business placed with each:
CARRIER COMPANY
% OF
BUSINESS
AGENCY/CONTRACT
ADMITTED OR
NON ADMITTED
# OF YEARS
REPRESENTED
A.M. BEST RATING
1.
Yes No
2.
Yes No
3.
Yes No
4.
Yes No
5.
Yes No
14.
Has any carrier terminated any of its agency contracts with the applicant within the last 5 years?
YES
NO
(If yes, please provide details on separate sheet).
16.
Does the applicant place coverage for risks involved in petroleum exploration and extraction, mineral
exploration and mining, or hazardous waste operations with significant pollution exposures?
YES
NO
(If yes, attach an explanation).
IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 3 of 6
May not be copied without permission.
Policy Period Carrier Limits Deductible Premium Retroactive Date
17.
Does the applicant place coverage for any client with watercraft or property located in a coastal or
hurricane-prone area (AL, FL, GA, LA, MS, NC, SC, NJ, NY, DC, TX or VA)? (If yes, complete “Coastal
Insurance supplement).
YES
NO
18.
Does the applicant place property/casualty insurance for clients in the energy industry? If so, what % of
annual agency commission income does this represent? ____%
YES
NO
19.
Office Procedures
YES
NO
N/A
a.
Do you utilize a coverage checklist which requires the insured’s signature?
b.
Are copies of binders distributed to the insured and/or the company within specific
guidelines?
c.
Are all applications, policies and endorsements checked for accuracy?
d.
Does the agency have a diary/suspense system?
e.
Is a written request required from any insured who desires to change or cancel coverage?
f.
Is a policy expiration list maintained?
g.
Do you document the file in writing regarding all business related conversations?
h.
Are all incoming documents date identified?
i.
Are files marked to ensure certificate holders are notified of cancellation or material changes?
j.
Does applicant have a procedure in place to ensure proper disclosure of policy exclusions?
20.
Has the applicant and/or any of its past or present owners, principals, shareholders, members, partners,
officers, employees, managers, solicitors, subsidiaries, affiliates and/or any other person or organization
proposed for insurance been the subject of or been involved in or had knowledge of any pending or
completed investigative or administrative proceeding by a state or federal regulatory agency, review board
or insurance department or had its/his/her license suspended or revoked or forfeited?
YES
NO
(If yes, attach an explanation).
21.
Has any policy or application for similar insurance on the applicant’s behalf or any of its owners, officers,
partners, members, employees or solicitors, or on behalf of any predecessor in business ever been
declined, cancelled or renewal refused? “NOT APPLICABLE IN MISSOURI”.
YES
NO
(If yes, attach an explanation).
22.
How many claims have been made against the applicant or predecessor insured person or entity or any of its past or present
employees, shareholders, partners, principals, members, owners, employees or solicitors within the last 5 years?
(If any, please complete a Supplemental Claim Form and provide 5-year company loss
runs).
0 1 2 3 or more
23.
Does any prospective or predecessor insured person or entity have knowledge of any act, error, omission,
proceeding, event or development, which may reasonably be expected to give rise to a Claim against the
applicant agency, past or present owners, officers, partners, principals, employees or solicitors, or its
predecessors(s) in business? (If yes, please complete a Supplemental Claim Form).
YES
NO
Please indicate the number:
0 1 2 3 or more
24.
If YES to 22 or 23, have they been reported to your Errors and Omissions insurance carrier?
If they have not, please provide an explanation.
YES
NO
25.
Five-Year Errors & Omissions Insurance History: No Errors & Omissions Insurance Currently in Force
IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 4 of 6
May not be copied without permission.
APPLICANT FRAUD WARNINGS
NOTICE TO ARKANSAS 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 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 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.
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 KANSAS APPLICANTS: 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 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 MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who 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 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 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.
IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 5 of 6
May not be copied without permission.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: 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 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 PUERTO RICO APPLICANTS: Any person who knowingly and with the intention of
defrauding presents false information in an insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more
than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be
sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more
than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both
penalties. Should aggravating circumstances [be] present, the penalty thus established may be
increased to a maximum of five (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
NOTICE TO 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 fines and confinement in prison.
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.
NOTICE TO 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 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.
NOTICE TO ALL OTHER STATES: Any person who knowingly and willfully presents false information in an
application for insurance may be guilty of insurance fraud and subject to fines and confinement in prison. (In
Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and
may subject the person to penalties).
NOTICE TO NEW YORK 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 shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
IA-APP (08/15) © 2015 X.L. America, Inc. All Rights Reserved. Page 6 of 6
May not be copied without permission.
NOTICE TO APPLICANT – PLEASE READ CAREFULLY BEFORE SIGNING
THE APPLICANT AND AGENCY ACCEPTS NOTICE THAT ANY POLICY ISSUED WILL APPLY ON A "CLAIMS-MADE" BASIS. The
undersigned is authorized by and acting on behalf of the Applicant and represents that all statements and particulars herein are true,
complete and accurate and that there has been no suppression or misstatements of fact and agrees that this application shall be the
basis of coverage.
THE APPLICANT AND FIRM ACCEPTS NOTICE THAT THEY ARE REQUIRED TO PROVIDE WRITTEN NOTIFICATION TO THE
COMPANY OR ANY CHANGES TO THIS APPLICATION THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND
ANY PROPOSED EFFECTIVE DATE. THE APPLICATION MUST BE SIGNED BY AN ACTIVE OWNER, PARTNER, PRINCIPAL,
OFFICER OR MEMBER OF THE APPLICANT.
Date
Signature
Printed Name Signature
Title of Person Signing the Application
Florida License Identification Number of Agent
SIGNING THIS FORM OR TENDERING PREMIUM WITH THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE
COMPANY TO COMPLETE THE INSURANCE.
Application must be signed and dated to be considered for quotation. A properly completed, original, signed and dated application will
allow for prompt issuance of coverage, should quotation be offered and accepted.
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PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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