Fillable Renewal Application for Agents and Brokers Errors and (Risk Placement Services, Inc.)

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Renewal Application for Agents and Brokers Errors and (Risk Placement Services, Inc.)

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QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC 30 08 03 17 Page 1 of 5
Instructions
If space is insufficient to answer any question fully, attach a separate sheet.
If response is none, state NONE.
1. Applicant information
Full name of applicant
Principal business premise street address
City State Zip
Contact person Email address
Phone number Fax
2. All following questions refer to the last 12 months or fiscal period only
a. Has there been any change in the agency’s ownership, nature of business or any newly formed or
acquired entities?
Yes No
If yes, provide details on a separate sheet and indicate if additional coverage is required in such respect.
b. What was your total commission and fees for the last twelve months for all lines of business?
Current year $
Past year $
2 year prior $
3. Property & Casualty (P&C) Insurance Operations:
Total P&C Insurance Premium Volume:
$
Total P&C Commission/Fee Income:
$
Total P&C
Net Commission/Fee Inco
me:
$
4. P&C - Personal & Commercial Lines: Indicate the percentage of commission/fee income for each - This P&C
section must total 100%
PERSONAL LINES
Auto (Standard)
%
Pleasure Boats/Craft %
Auto (Non-Standard/Assigned Risk) % Umbrella/Excess %
Homeowners/Fire (Standard)
% Farm (Personal) %
Homeowners/Fire (Non-Standard) % Other (Describe) %
COMMERCI
AL LINES:
Fire (Standard) % Crop %
Fire (Non-Standard)
%
Medical Malpracti
ce
%
SMP/BOP/Package
%
Professional Liability
%
Commercial General Liability % Inland Marine %
Umbrella/Excess
%
Wet Marine
%
Auto (Standard)
%
Bonds - Surety
%
Auto (Non-Standard) % Bonds - All Other %
Long Haul Trucking
%
Aviation
%
Workers Compensation % Directors & Officers %
Renewal Application for Agents and Brokers
Errors and Omissions Liability Insurance
(Claims Made or Claims Made and Reported Basis)
QBPC 30 08 03 17 Page 2 of 5
Employment Practices
%
Livestock
%
Liquor Liability - Restaurant
%
Liquor Liability - Bars/Clubs %
Other (Describe):
%
Other (Describe): %
CALCULATE TOTAL (MUST EQUAL 100%)
%
5. Life, Accident & Health (A&H) Insurance and Other Financial Products:
Total Life, Accident & Health Premium Volume: $
Total Life, Accident & Health Commission/Fee Income: $
Total Life, A&H Net Commission/Income: $
6. Life, A&H Insurance and Other Financial Products - Indicate the percentage of commission/fee income for each
- This section must total 100%
Individual Life % Variable Life/Annuities %
Individual A&H
%
Equity Indexed Annuities
%
Group Life
%
Mutual Funds
%
Group A&H % Securities %
Long Term Care
%
Life Settlement/Viaticals
%
Fixed Annuities
%
Other (Describe):
%
CALCULATE TOTAL (MUST EQUAL 100%)
%
7. OTHER PRODUCTS AND/OR SERVICES (Total Gross Income):
Human Resource Services $
Employee Benefit Plan Consulting & Administration Services $
Third Party Insurance Claims Administration Services $
Other (Describe): $
8. PREMIUM VOLUME
Total premium volume for Property & Casualty the past 12 months: $
Total premium volume for Life and Health the past 12 months: $
Total premium volume for all lines the past 12 months: $
9. CARRIER RATING
Provide a percentage of placements (response must equal 100%) – provide a list of any carriers who have A.M. Best rating
below B+, do not have an A.M. Best Rating or are Demotech rated.
A.M. Best Rated B+ or better
A
.M. Best less than B Does not have A.M. Best Rating Demotech Rated Carriers
% % % %
10. Have you become involved in any new negotiation, placement or binding of reinsurance for any
entity or placement of coverage with any self-insured risk assuming organization or risk retention
group?
Yes No
If yes, provide details on a separate sheet.
11. What percentage of your total revenue for the last twelve months was derived from the following?
Appraisal Services Claims Adjusting* Claims Administration* Wholesaler / Retailer
% % % %
Consulting for a fee Program Administration Premium Financing Reinsurance Intermediary
% % % %
Risk Management for a fee Structured Settlements Third Party Administration* Other (specify)
% % % %
*(If any percentage, complete TPA/Claim Administrators Supplement)
UNDERWRITING QUESTIONS
1. Has any Insurer’s audit stated that the Applicant exceeded its premium cap or underwriting
authority or that you did not issue the correct policy wording and/or endorsements as mandated by
the insurer?
Yes No
If yes, provide details on a separate sheet and describe what remedial actions have been taken to avoid reoccurrence.
2. Has any MGA, Underwriting Manager or Program Administrator contract authority been canceled,
revoked or terminated or has any Insurer added any restrictions to the Applicant's underwriting or
claim handling authority?
Yes No
If yes, provide details on a separate sheet.
QBPC 30 08 03 17 Page 3 of 5
3. Has the Applicant delegated any underwriting, claim handling and/or any other authority to any sub
agent?
Yes No
If yes, provide details on a separate sheet and a copy of your contract with the Insurance Company which permits such
delegation of authority.
4. Has the Applicant and/or any of its principals, partners, officers, directors, trustees, employees, or
any person(s) or entity(s) proposed for this insurance become aware of any
a. new claim arising out of professional services that has been made against them or any
person(s) or entity proposed for this insurance?
Yes No
b. fact, circumstance, situation, incident or allegation of negligence or wrongdoing, which might
afford grounds for any claim such as would become the subject matter of the proposed
insurance?
Yes No
c. change to any previously reported claim or circumstance? Yes No
If yes, to either a., b. or c. above, complete the Supplemental Claim Form for each claim or circumstance.
d. pending or completed investigative or administrative proceeding against any person(s) or entity
proposed for this insurance?
Yes No
e. person(s) or entity proposed for this insurance having had their license suspended, revoked,
forfeited or disciplined by a state insurance department, federal agency, regulatory agency or
professional review board?
Yes No
If yes, to either d. or e. above, provide details on a separate sheet
5. Indicate the Limits of Liability requested
Indicate the Deductible requested
Limit Per Claim / Aggregate Deductible Per Claim
$1,000,000 / $1,000,000 $ 5,000
$2,000,000 / $2,000,000 $ 10,000
$3,000,000 / $3,000,000 $ 15,000
$4,000,000 / $4,000,000 $ 20,000
$5,000,000 / $5,000,000 $ 25,000
$ 50,000
higher amount – Specify: $
Representations
BY SIGNING THIS APPLICATION THE APPLICANT AGREES THAT:
The Applicant has made a comprehensive internal inquiry or investigation to determine whether anyone in the Applicant
organization is aware of any actual or alleged fact, circumstance, situation, error or omission which may reasonably be
expected to result in a claim, and have divulged any and all such situations in Questions 9 a or b. of this application; and
The application and attachments, and all of the statements and answers given therein are:
Accurate and complete to the best of the Applicant's knowledge;
Representations the Applicant is making on behalf of all persons and organizations proposed to be insured;
A material inducement to the Company to provide a proposal for insurance and any policy that the Company issues is
issued on reliance upon these representations; and
Deemed attached herein, incorporated into, and form a part of the policy.
The Applicant agrees to report to the Company in writing any material change in its operations, conditions, or answers
provided in this application that may occur or be discovered after the completion date of the application and before the
effective date of the policy. On receipt of any such written notice, the Company has the right to modify or withdraw any
proposal for insurance the Company has offered, at the sole discretion of the Company.
Signing of this application does not bind the Company to offer, nor the Applicant to accept insurance, but it is
agreed that this application shall be the basis of the insurance and it will be deemed attached to and made a part of
the policy should a policy be issued.
Any person who, knowingly and with the intent to defraud any insurance company or other person, files an
application for insurance containing any false information or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which may be considered a crime.
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW WHERE INDICATED. IF THIS POLICY
IS ISSUED, THIS SIGNED STATEMENT WILL BE ATTACHED TO THE POLICY.
QBPC 30 08 03 17 Page 4 of 5
No fact, circumstance, situation or incident indicating the probability of a claim or action for which coverage may be afforded
by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that
which is disclosed in this application. It is agreed by all concerned that if there be knowledge of any such fact, circumstance,
situation, incident or allegation of negligence or wrongdoing, any claim subsequently emanating there from shall be
excluded from coverage under the proposed insurance.
The policy applied for is SOLELY AS STATED IN THE POLICY, if issued, which provides coverage on a claims made basis
for ONLY THOSE “CLAIMS” THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD, unless
an automatic extended reporting period is available or the extended reporting period option is exercised in accordance with
the terms of the policy. The policy has specific provisions detailing claim reporting requirements.
New York Notice: This application is for claims-made coverage. There shall be no coverage for “Claims” arising out of
“Wrongful Acts” or “Personal Injuries” which took place prior to the “Retroactive Date”. Upon termination of coverage for any
reason, a sixty-day Automatic Extended Reporting Period will apply. For an additional premium, an Optional Extended
Reporting Period of thirty-six months can be purchased. There is no coverage for “Claims” first made against the Insured
after the ”Policy Period” or Automatic Extended Reporting Period unless the Optional Extended Reporting Period is
purchased. Gaps in coverage may arise if the policy is not replaced with comparable claims-made coverage upon expiration
of either the policy or Optional Extended Reporting Period, if purchased.
During the first several years of claims-made coverage, claims-made rates are comparatively lower than occurrence rates,
and the insured can expect substantial annual premium increases, independent of overall rate level increases, until the
claims made risk reaches full maturity.
Fraud Warnings
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 Alaska residents: “A person who knowingly and with intent to injure, defraud, or deceive an insurance
company, files a claim containing false, incomplete, misleading information may be prosecuted under state law.”
Notice to Arizona residents: “For your protection Arizona law requires the following statement to appear on this form.
Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil
penalties.”
Notice to California residents:“For your protection California law requires the following to appear on this form. Any
person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.”
Notice to Colorado residents:“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 Delaware residents:“Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a
statement of claim containing any false, incomplete, or misleading information is guilty of a felony.”
Notice to Florida residents:“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 Idaho residents:“Any person who knowingly and with intent to defraud or deceive any insurance company, files
a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.”
Notice to Indiana residents:“A person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.”
Notice to Kansas residents:“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
QBPC 30 08 03 17 Page 5 of 5
any fact material thereto.”
Notice to Kentucky residents:“Any person who knowingly and with intent to defraud any insurance company or other
person files a statement of claim or an application 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 Maryland residents:“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 Maine residents:“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 a denial of insurance
benefits.”
Notice to Minnesota residents:“A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.”
Notice to New Hampshire residents:“Any person who, with a purpose to injure, defraud, or deceive any insurance
company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution
and punishment for insurance fraud, as provided in RSA 638:20.”
Notice to New Jersey residents:“Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.”
Notice to New Mexico residents:“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 residents:“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 residents:“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 residents:“WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive an
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 residents:“Any person who knowingly and with intent to defraud any insurance company or other
person files a 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 Tennessee, Virginia, and Washington residents:“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 Texas residents:“Any person who knowingly presents a false or fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines and confinement in state prison.
Must be signed within 90 days of the proposed effective date.
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Renewal Application for Agents and Brokers Errors and (Risk Placement Services, Inc.)

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Completed 30 July 2020

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