Fillable PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS MANAGING GENERAL (Risk Placement Services, Inc.)

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PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS MANAGING GENERAL (Risk Placement Services, Inc.)

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IA-APP-MGA (12/09) © 2009 X.L. America, Inc. All Rights Reserved. Page 1 of 3
IA-APP-MGA-FL (09/11) May not be copied without permission.
IA-APP-MGA-MA (03/10)
Greenwich Insurance Company Indian Harbor Insurance Company
PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS –
MANAGING GENERAL AGENTS, WHOLESALE AGENTS, PROGRAM
ADMINISTRATORS AND MANAGING UNDERWRITERS
Name of applicant agency/D/B/A if applicable:
(a) Number of producers from whom you receive business:
(b) Number of such producers you have appointed as agents with binding authority:
Premium Volume: $
(c) Lines of business for which such producers are granted authority:
(d) What checks and supervision do you exercise over your producers?
(e) Do you require and verify that your producers carry E&O coverage? Yes No
What is your minimum E&O limit requirement for sub-producers?
(f) Does your contract with producers include a hold-harmless agreement in your favor? Yes No
PLEASE INCLUDE A SAMPLE COPY OF YOUR HOLD-HARMLESS AGREEMENT WITH THIS
APPLICATION.
(g) List all functions you perform as Managing General Agent or Program Administrator or agent with
binding authority:
Qu
oting:
Yes No Max limit of your authority:
Underwriting: Yes No Max limit of your authority:
Binding: Yes No Max limit of your authority:
Policy issuance: Yes No
Claims adjusting:
Yes No Max limit of your authority:
Claims administration: Yes No Describe:
Actuarial service: Yes No
Loss control:
Yes No
Reinsurance placement:
Yes No
IA-APP-MGA (12/09) © 2009 X.L. America, Inc. All Rights Reserved. Page 2 of 3
IA-APP-MGA-FL (09/11) May not be copied without permission.
IA-APP-MGA-MA (03/10)
(h) What fees have been generated in the last 12 months from operations listed below?
$ Claims Adjusting $ Insurance Consulting/Advising
$ Third Party Administrator $ Risk Management Consultant
(i) What is the approximate percentage breakdown of the total annual volume you do as?
Agent % Retailer:
Broker % Business direct from insureds: %
Managing General Agent % Wholesaler:
Surplus Lines Broker % Business accepted from other agents: %
Consultant (for a fee) % Reinsurance: %
Reinsurance % Facultative: %
Other (Specify) % Treaty: %
Must Total: 100% 100%
(j) Please provide complete details on a separate sheet of any specialty programs you manage.
(k) What minimum Best Ratings do you require as regards the companies with which you place
business?
(l) Is all rating and policy issuance generated by an electronic system created by the companies you
represent?
Yes No
If response to (l) is “No” please provide a copy of the most recent audit report from all
companies that do not have an electronic system.
(m) Do you have discretion over pricing, terms and conditions for the programs that you manage?
Yes No If Yes, attach explanation.
(n) Do you have any discretion over the use of or drafting of endorsements for any of these programs?
Yes No If Yes, attach explanation.
(o) How often is an audit performed by the insurers you represent?
(p) List and describe the circumstances behind all insurance carriers who MGA/MGU and or PA
contracts have been terminated in the last 5 years.
FRAUD WARNINGS
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment for 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 policy holder or claimant for the purpose
of defrauding or attempting to defraud the policy holder 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 D.C.
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 insurance company files a statement of claim or an application
IA-APP-MGA (12/09) © 2009 X.L. America, Inc. All Rights Reserved. Page 3 of 3
IA-APP-MGA-FL (09/11) May not be copied without permission.
IA-APP-MGA-MA (03/10)
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 purposes of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly
and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and 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 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 violation. 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
RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefitor
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 STATE APPLICANTS: 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.
Fraud Language updated (02/10)
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.
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:
Title:
Applicant’s Signature:
Date:
Agent/Broker Name:
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PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS MANAGING GENERAL (Risk Placement Services, Inc.)

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Completed 23 November 2020

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