Fillable PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS AFFORDABLE CARE (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS AFFORDABLE CARE (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS AFFORDABLE CARE (Risk Placement Services, Inc.)

On average this form takes 14 minutes to complete

The PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS AFFORDABLE CARE (Risk Placement Services, Inc.) form is 5 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
IA-APP-ACA (01/14) © 2014 X.L. America, Inc. All Rights Reserved. Page 1 of 5
May not be copied without permission.
PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS
AFFORDABLE CARE SUPPLEMENT
Name of applicant agency /D/B/A if applicable:
1.
Does your agency place or intend to place any health insurance in the next twelve (12)
months?
Yes
No
If no, please skip the remaining questions and sign and date this supplement. If yes, please complete the
remaining questions and sign and date the supplement.
2.
Please provide:
(a)
$
(b)
$
3.
Please provide a breakdown of the Health Insurance Premium Written (Totals should equal total presented in
Question 2. (b) above):
Health Insurance
Premium Volume
Number of Policies
Group Health
Individual Health
Total Health Insurance
4.
Please estimate the total percentage of business you anticipate placing in the next twelve (12) months with:
(a)
$
(b)
$
5.
Does any member of your staff currently or plan to act as a Navigator?
Yes
No
If yes, please provide details:
6.
Please list your Open Market Insurers:
Insurer
Number of Plans Available
IA-APP-ACA (01/14) © 2014 X.L. America, Inc. All Rights Reserved. Page 2 of 5
May not be copied without permission.
7.
Are all staff members who service clients licensed by the Department of Insurance?
Yes
No
If no, please provide details:
8.
Do you have a specialist(s) in your agency who places health insurance?
Yes
No
If yes, please provide the following:
(a)
Name of Individual:
(b)
Professional Designation:
(c)
ACA Education Hours in the past twelve (12) months, including the provider:
(d)
Yes
No
(e)
Yes
No
(f)
9.
Do you accept Business from sub-producers?
Yes
No
If yes, please provide details:
10.
Is your notice of non-renewal procedure different for Health Insurance vs. other lines?
Yes
No
If yes, please provide details:
11.
Do you provide ANY financial advice concerning the exchange/market place vs. the
open market:
Yes
No
If yes, please provide details:
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO
MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
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.
IA-APP-ACA (01/14) © 2014 X.L. America, Inc. All Rights Reserved. Page 3 of 5
May not be copied without permission.
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 HEREOF.
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 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 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 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.
IA-APP-ACA (01/14) © 2014 X.L. America, Inc. All Rights Reserved. Page 4 of 5
May not be copied without permission.
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.
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).
IA-APP-ACA (01/14) © 2014 X.L. America, Inc. All Rights Reserved. Page 5 of 5
May not be copied without permission.
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.
Applicant:
Title:
Applicant’s Signature:
Date:
Agent/Broker Name:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS AFFORDABLE CARE (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document