Fillable PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS SUPPLEMENTAL CLAIM (Risk Placement Services, Inc.)

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PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS SUPPLEMENTAL CLAIM (Risk Placement Services, Inc.)

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IA-APP-CLAIM (11/06) © 2006 X.L. America, Inc. All Rights Reserved. Page 1 of 2
IA-APP-CLAIM-FL (09/11) May not be copied without permission.
IA-APP-CLAIM-MA (03/10) IA-APP-CLAIM-ME (02/10)
Greenwich Insurance Company Indian Harbor Insurance Company
PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS
SUPPLEMENTAL CLAIM INFORMATION FORM
APPLICANT’S INSTRUCTIONS:
This form is to be completed by the Applicant who has been involved in any claim or suit or is aware of any facts,
circumstances, acts, errors or omissions which may give rise to a professional liability claim.
COMPLETE ONE FORM FOR EACH CLAIM OR CIRCUMSTANCE AND ATTACH COMPANY LOSS RUN.
If space is insufficient to answer any question fully, attach a separate sheet. Answer ALL questions completely.
1. Full name of Applicant: ________________________________________________________
2. Full name of individual(s) or firm involved in claim: ___________________________________
3. Full name of claimant: __________________________________________________________
4. Indicate whether: Claim/Suit or Incident
5. Date of alleged error: __________
6. Date of claim: __________
(a): Description of claim: (Provide enough information to allow evaluation and use a separate exhibit if additional
space is required):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(b): Description of case and events: ___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
8. IF CLOSED, TOTAL LOSS PAID INCLUDING DEDUCTIBLE: $ ______
9. IF PENDING:
Claimant’s Settlement Demand $ _________
Defendant’s Offer for Settlement $ _________
Insurer’s Loss Reserve $ _________
Deductible $ _________
Is Claim in Suit: Yes No
If Yes, Amount asked in complaint $ ______
10. Name of Insurance Carrier: ___________________________________________________
11. Please describe procedures instituted to avoid like claims: __________________________________
IA-APP-CLAIM (11/06) © 2006 X.L. America, Inc. All Rights Reserved. Page 2 of 2
IA-APP-CLAIM-FL (09/11) May not be copied without permission.
IA-APP-CLAIM-MA (03/10) IA-APP-CLAIM-ME (02/10)
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
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)
Applicant:
Title:
Applicant’s Signature:
Date:
Agent/Broker Name:
Agent/Broker’s Florida License Identification Number:
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PROFESSIONAL LIABILITY INSURANCE FOR INSURANCE AGENTS SUPPLEMENTAL CLAIM (Risk Placement Services, Inc.)

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Completed 23 November 2020

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