ENDURANCE AGENCY ADVANTAGE APPLICATION
THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A “CLAIMS MADE” BASIS WHICH APPLIES ONLY TO
CLAIMS WHICH BOTH FIRST ARISE AND ARE REPORTED WHILE THE POLICY IS IN FORCE.
4. Limit of Liability desired: $ each claim/aggregate Deductible: $ each claim.
5. License Number(s): Date First Licensed: Date Firm Established:
6. State Applicant’s Annual Premium Volume and Commission:
Premiums Commissions
Last 12 months:
Est. next 12 months:
7.
State the approximate breakdown of total annual volume for each column
1. Name:
Individual
(exactly as shown on license - attach copy of license)
Partnership
D/B/A (if applicable):
Corporation
2. P.O Box: Phone No.:
Street Address: Fax No.:
City, State, Zip: Email:
List additional locations on separate sheet, if necessary
Requested
If applicable please list the names of any subsidiaries and a description of their operations: Effective Date:
Website:
3. List the following information and identify all owners, partners, officers, directors, and licensees:
(attach separate sheet, if necessary)
NAME RESIDENCE ADDRESS TITLE
DATE OF
BIRTH
YEARS INS.
EXPERIENCE
7a. Transacting as:
7b. Lines of Business:
Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . %
Broker . . . . . . . . . . . . . . . . . . . . . . . . . . %
Surplus Lines Broker. . . . . . . . . . . . . . %
Managing General Agent. . . . . . . . . . . %
Underwriting Manager . . . . . . . . . . . . . %
Program Manager. . . . . . . . . . . . . . . . . %
Free Consultant . . . . . . . . . . . . . . . . . . %
Life - Health Agent / Broker. . . . . . . . . %
Adjuster. . . . . . . . . . . . . . . . . . . . . . . . . %
Appraiser . . . . . . . . . . . . . . . . . . . . . . . %
Financial Planner . . . . . . . . . . . . . . . . . %
Reinsurance Broker . . . . . . . . . . . . . . %
Other (Explain) . . . . . . . . . . . . . . . . . . . %
MUST TOTAL 100%
PUG 0004 0814 Page 1 of 5
Commercial Fire & Inland Marine . . . . %
Commercial General / Excess Liab. . . %
Non-Artisan Contractors GL . . . . . . . . %
Commercial Auto / Garage / Dealers . %
Trucking (Long Haul) . . . . . . . . . . . . . . %
Workers Comp . . . . . . . . . . . . . . . . . . . %
BOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . %
Professional Liability . . . . . . . . . . . . . . %
Ocean Marine . . . . . . . . . . . . . . . . . . . . %
Aviation . . . . . . . . . . . . . . . . . . . . . . . . . %
Surety . . . . . . . . . . . . . . . . . . . . . . . . . . %
Bonds other than Surety . . . . . . . . . . %
Homeowners / Dwelling Fire . . . . . . . %
Personal Auto . . . . . . . . . . . . . . . . . . . %
Personal Floaters . . . . . . . . . . . . . . . . %
Life / Accident / Health / Group . . . . . %
Other (Explain) . . . . . . . . . . . . . . . . . . . %
MUST TOTAL 100%
5300 West Atlantic Ave. • Suite 610 • Delray Beach, FL 33484
Tel: (561) 455-7715 • Toll Free (800) 281-4234 • Fax: (561) 455-7720
Email: info@PUGinsuranceAgency.com • Web: www.professionalunderwritinggroup.com
Whenever used in this Application, the term “Applicant” means the Named Insured and any other entity proposed for coverage.
PROFESSIONAL UNDERWRITING GROUP, INC.
7c. Business written directly for your
own insureds
. . . . . . . . . . . . . . . . . . %
Percentage of business which is direct billed by carriers
Business accepted from
other agents and brokers
. . . . . . . . . . . %
Auto % Homeowners % Commercial % Other %
8a. Name all companies the applicant represents under direct Agent or Broker Agreements:
COMPANY ADDRESS
DATE
APPOINTED
VOLUME
LINES OF
BUSINESS
NAME LINES OF BUSINESS
VOLUMECOMPANIES USED
8b. List General Agents, MGA’s and Surplus Line Brokers with whom you place business:
8c.
State percentage of
business
written through:
Assigned Risk or State Fund Pools: % Risk Purchasing Groups %
Risk Retention Groups: % Alien Non-Admitted Carriers %
9. Have any Companies, General Agents or other markets withdrawn from your agency in the past three years?
Yes
No If yes, explain:
10.
Name all companies for which the applicant acts as G.A., Managing General Agent or Underwriting Manager:
11.
Specify the maximum limit(s) the applicant is authorized to bind:
12a. Does agency specialize in writing any class of risk (Examples: Auto Dealers, Contractors, Truckers, etc.)?
Yes
No If yes, what class:
12b. How long writing this class years?
12c. Percentage of Agency’s Volume %.
12d. What Markets used:
AMOUNT
Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
General Liability
. . . . . . . . . . . . . . . . . . $
Auto Liability
. . . . . . . . . . . . . . . . . . . . . $
AMOUNT
Auto Physical Damage. . . . . . . . . . . . . $
Homeowners
. . . . . . . . . . . . . . . . . . . . . $
Excess Liability
. . . . . . . . . . . . . . . . . . $
PUG 0004 0814 Page 2 of 5
13a. NUMBER OF STAFF: FULL TIME PART TIME
Principals
Agents / Brokers / Solicitor (Not listed as principals)
Service / Raters
Accounting / Bookkeeping
Clerical / Filing
Independent Contractors (Not salaried Employees)
Other (Explain) TOTAL
13b. Do persons responsible for the transaction of insurance speak and write English?
Yes
No
What other languages are spoken in your office or with your clients?
14a. Does the agency utilize any form of
computer or automation system?
Yes
No
14b. What type:
In House
Batch
Manual
Other - Explain:
14c. Name the Automation Vendor:
14d. Name of Software System and Program:
14e. Version Date of Installation:
14f.
Hardware
Batch
Multi-User
Number of Stations:
PLEASE INDICATE FUNCTIONS PERFORMED:
Accounting
Claims
Renewal Lists
Rating
MVR’s
Applications
Policy Information
Policy Issuance
Financing
Word Processing
Other (Explain)
15.
List all State approved or Professional Association sponsored insurance continuing education courses or seminars
attended by agency Principal and Licensees during the past 12 Months
:
16a.
List all Professional Liability, “E & O” or Legal Expense insurance carried during the past five years. If none, state “NONE.
16b. Retroactive Date of current policy:
17.
Is the principal / principals active in the business? Yes No
18.
Does the agency maintain a binder log?
Yes No
19.
Does the agency use “Power of Attorney” to represent the insured? Yes No
20.
Is all incoming mail date stamped?
Yes No
21.
Are records of coverage rejections maintained?
Yes No
INSURANCE CO.
LIMITS OF
LIABILITY
DEDUCTIBLE
(IF ANY)
PREMIUM
INCEPTION
Month / Day / Year
EXPIRATION
Month / Day / Year
CLAIMS
YES NO
PUG 0004 0814 Page 3 of 5
Have any claims or suits been made during the past five years against the applicant or any of its predecessors in
business, or any of the past or present partners, directors, officers, solicitors or employees?
Yes
No
(If yes, attach statement giving detail and status of each claim including dates, amount of claim, deductible,
payments and open reserves.)
Is the applicant, after inquiry of each person proposed for insurance, aware of any circumstance, error, omission
or offense which may result in a claim being made against the applicant or any of its predecessors in business, or
any of the past or present partners, directors, officers, solicitors or employees?
Yes
No
If the response to Question 22 and/or Question 23 is “Yes,” please attach complete details.
NOTE: It is agreed that any claim or lawsuit against the Applicant, or any principal, partner, managing member,
director, officer or employee of the Applicant, or any other proposed insured, arising from any fact, circumstance,
act, error or omission disclosed or required to be disclosed in response to Questions 22-23 is hereby expressly
excluded from coverage under the proposed insurance policy.
Has the Applicant reported the matters listed in Questions 22 - 23 to its current or former insurance carrier?
Yes
No
N/A
Has any application for insurance on behalf of the applicant or any of its predecessors in business been declined
or canceled, or renewal of such insurance been refused? ? (Missouri applicants need not answer this question.)
Yes
No (If yes, explain.)
Has the applicant or any person or employee of any applicant proposed for insurance ever been subject to
disciplinary action by any State licensing agency or regulatory body?
Yes
No
Indicate all Insurance Professional Associations of which you are a member:
IIAA
PIA
American Agents Alliance
WAIB
AAMGA
NAPSLO
Other
The undersigned being authorized by, and acting on behalf of the applicant and all persons concerned seeking
insurance, has read and understands this application, and declares all statements set forth herein are true,
complete and accurate. The undersigned further declares and represents that any occurrence or event taking
place prior to the effective date of the policy applied for, which may render inaccurate, untrue or incomplete any
statement made herein will be immediately reported in writing to the insurer. The undersigned acknowledges
and agrees that the submission and the insured’s receipt to such written report, prior to the inception of the policy
applied for, is a condition precedent to coverage.
The applicant accepts notice that any policy issued will: (1) Only apply on a “claims made” basis and that the
deductible will apply to loss payment and (whether or not loss payment is made) to claims expense, as those terms
are defined in the Policy; (2) Not insure against damages resulting from any claim or claim expense, as that term is
defined in the policy, alleged to have occurred prior to the Inception Date of the policy unless the Underwriter shall
agree to insure damages resulting from claim or claim expense alleged to have occurred prior to the Inception Date
but after an agreed upon Retroactive Date.
The undersigned authorized officer of the Applicant declares that the statements set forth herein are true. The
undersigned authorized officer agrees that if the information supplied on this Application changes between the date of
this Application and the effective date of the insurance, he/she shall, in order for the information to be accurate on the
effective date of the insurance, immediately notify the Insurer of such changes, and the Insurer may withdraw or modify
any outstanding quotations or authorizations or agreements to bind the insurance.
Signing of this Application does not bind the Applicant or the Insurer to complete the insurance contract, but it is agreed
that this Application shall be the basis of the contract should a policy be issued, and it will be attached to and become
part of the Policy.
All written statements and materials (including any information provided in the attached Appendices) furnished to the Insurer
in conjunction with this Application are hereby incorporated by reference into this Application and made a part hereof.
The applicant hereby authorizes the Underwriters, and/or their representatives by signing this application, to contact any
prior insurer and obtain any details, or prior loss information, or obtain any other information from any source including
consumer credit information, which the Underwriters deem important in the underwriting of the insurance applied for
by this application.
Name of Applicant Dated:
Signature of Owner, Partner or President Title:
22.
23.
24.
25.
26.
27.
28.
29.
PUG 0004 0814 Page 4 of 5
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FRAUD NOTIFICATION
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION OF INSURANCE
CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMIT A FRAUDULANT INSURANCE ACT, WHICH IS A CRIME.
NOTICE TO STATE APPLICANTS:
ALABAMA: ANY PERSON WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO RESTITUTION, FINES, OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.
ARKANSAS, NEW MEXICO, RHODE ISLAND OR WEST VIRGINIA: ANY PERSON WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CONFINEMENT IN PRISON.
COLORADO: 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.”
DISTRICT OF COLUMBIA: 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.
KANSAS: ANY PERSON WHO COMMITS A FRAUDULENT INSURANCE ACT IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION, FINES AND
CONFINEMENT IN PRISON. 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 OR INSURANCE AGENT OR BROKER, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR INSURANCE,
OR THE RATING OF AN INSURANCE POLICY, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT UNDER AN INSURANCE POLICY, WHICH SUCH PERSON KNOWS
TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY MATERIAL FACT THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
KENTUCKY: 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.
LOUISIANA: ANY PERSON WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN PRISON.
MARYLAND: 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.
NEW JERSEY: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO
CRIMINAL AND CONFINEMENT IN PRISON.
NEW YORK: 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.
OHIO: 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.
OKLAHOMA: 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.
OREGON: 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON
TO CRIMINAL AND CIVIL PENALTIES.
PENNSYLVANIA: 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.
TENNESSEE, VIRGINIA OR WASHINGTON: 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.
VERMONT: 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
PUG 0004 0814 Page 5 of 5
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