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and Omissions Liability Insurance INSURANCE CORPORATION (Risk Placement Services, Inc.)

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INSURANCE CORPORATION
QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC-3002 FL (09-16) Page 1 of 10
Instructions
If space is insufficient to answer any question fully, attach a separate sheet.
If response is none, state NONE.
General information
Full name of applicant
Principal business premise street address
City
State
Zip
Contact person
Email address
Phone number
Fax
Website
Date organized (MM.DD.YYYY)
Business is a
Corporation
Sole proprietorship
Other
Are there any predecessor organizations to the Applicant (any organization which was engaged in the
same essential types of insurance activities as the Applicant, in whose financial assets and liabilities
the Applicant is the majority successor in interest)?
Yes
No
If yes, name of predecessor organization(s)
Is the Applicant controlled by, owned by, or commonly owned, affiliated or associated with any other
organization?
Yes
No
If yes, are any services provided to such organization(s)?
Yes
No
If yes, provide details.
During the last five years has the Applicant been involved in, or are they presently considering or
contemplating:
Any merger or acquisition?
Yes
No
If yes, provide a complete explanation detailing liabilities assumed and any Errors and Omissions Liability Coverage
purchased by any predecessor organization.
A change in the nature of business operations?
Yes
No
If yes, provide details.
Application for Agents and Brokers Errors
and Omissions Liability Insurance
(Claims Made or Claims Made and Reported Basis)
________________________________________________________________
________________________________________________________________
_____________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
QBPC-3002 FL (09-16) Page 2 of 10
During the last five years has:
(a) The name of the Applicant been changed?
Yes
No
(b) Ownership of the Applicant changed?
Yes
No
If yes to either (a) or (b) above, provide details.
Does the Applicant have any subsidiaries or affiliated organizations?
Yes
No
If yes, provide the following for each subsidiary and affiliated company.
Name
Description of
Operations
% Ownership by
Applicant
Date Acquired,
Created or Affiliated
Domicile
State
%
%
%
Is coverage requested for any of the above organizations?
Yes
No
If yes, for which organization(s) is coverage requested?
Applicant operations
During the last five years has the Applicant placed business with any insurance company, reinsurer,
risk retention group, captive (or any other self-insurance plan or trust by whatsoever name) or any
other organization that has been declared bankrupt, insolvent, or been placed in receivership,
liquidation or rehabilitation or has been financially unable to meet all or part of its financial obligations?
Yes
No
During the last five years has the Applicant
(a) Negotiated, placed or bound reinsurance for any organization?
Yes
No
(b) Received commissions from, collected premiums or paid claims on behalf of any reinsurer?
Yes
No
(c) Placed coverage with any self insured risk assuming organization or risk retention group?
Yes
No
If yes to (a), (b) or (c) above, provide details.
Total commission and fees from all lines of business:
Estimate for the coming year
Last twelve months
One year prior
Year
Commission and Fees
Year
Commission and Fees
Year
Commission and Fees
$
$
$
Provide the total annual commission and fees from property and casualty that is placed with
Lloyd's of London
Other Non-United States domiciled insurers
$
$
List all non-United States domiciled insurers, where coverage is placed
Provide the percentage of total commission and fees for all lines of business that the Applicant acts as:
MGA, Underwriting Manager or
Program Administrator
Surplus Lines
Broker or Agent
Third Party
Administration (TPA)*
Claims
Administrator*
%
%
%
%
*Complete TPA / Claims Administrator Supplement
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
QBPC-3002 FL (09-16) Page 3 of 10
Property & Casualty (P&C) Insurance Operations:
Total P&C Insurance Premium
Volume:
$_______________
Total P&C Commission/Fee Income:
$_______________
Total P&C Net Commission/Fee
Income:
$_______________
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)
%
COMMERCIAL LINES:
Fire (Standard)
%
Crop
%
Fire (Non-Standard)
%
Medical Malpractice
%
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
%
Employment Practices
%
Livestock
%
Liquor Liability - Restaurant
%
Liquor Liability - Bars/Clubs
%
Other (Describe):
%
Other (Describe):
%
CALCULATE TOTAL (MUST
EQUAL 100%)
%
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:
$_______________
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%):
%
QBPC-3002 FL (09-16) Page 4 of 10
OTHER PRODUCTS AND/OR
SERVICES (Total Gross Income):
Human Resources Services
$
Employee Benefit Plan Consulting &
Administration Services
$
Third Party Insurance Claims
Administration Services
$
Other (Describe):
$
List your top five insurers by premium volume , the annual premium volume and % of commission or
fees, and the number of years represented for business that the Applicant places with each insurer
listed:
Insurer
Annual Premium Volume/% of
Commission and Fees
No. Years Represented
$
$
$
$
$
$
Provide the percentage of annual total gross income from the following
List all insurers you place business with an A.M. Best Rating below B+, or not rated along with the
annual premium volume and % of commission/fees and the # of years represented. Please include
this information on a separate sheet or report as needed.
Appraisal Services
Insurance Claims Administration*
Insurance Commissions
%
%
%
Insurance Consulting for a fee
Premium Financing
Reinsurance Intermediary
%
%
%
Risk Management for a fee
Third Party Administration*
Other (specify) .
%
%
%
*Complete TPA / Claim Administrator Supplement
Provide number of the Applicant's total staff (including part-time)
Active principals, partners,
officers, directors
Other employees
Total
+
+
=
Total number of staff hired within the
last twelve months
Total number of staff resigned, retired or terminated within the
last twelve months
Average number of years with the Applicant
Professional staff
Provide the following for each owner of the Applicant
Owner's Name
Title
Currently Active full
time with the
Applicant (Yes/No)
Total Number of
Years With the
Applicant
Total Number of
Years in the
Insurance Industry
Percentage
Ownership
%
%
%
%
Does the Applicant place homeowners, property or flood insurance for any insureds located in the
hurricane belt (AL, FL, GA, LA, MS, NC, NJ, SC or TX)?
Yes
No
If yes, does the Applicant always get a written sign-off from the client if they decline to purchase
Flood and/or Windstorm coverage?
Yes
No
QBPC-3002 FL (09-16) Page 5 of 10
If no, please explain.
What %, if any, of the applicant’s insurance business is serviced by carrier’s Service Center Operations: ___%
What % of the applicant’s staff has completed an E&O Loss Prevention Class or Seminar? ___%
Does the agency have an Agency Management System in place? ____Yes ____No
If so, is the same system used for all locations or offices of the applicant? ____Yes ___No. If no, please explain.
Are there any staff at the agency who hold insurance-related designations? If so, please provide this
information as a supplement including the staff member name and the designation(s) held.
Yes
No
When the Applicant receives a claim from an insured
What is maximum number of days within which the Applicant notifies the insurer?
What is the number of days after forwarding a notice to an insurer that the Applicant allows before
following up with the insurer to confirm the insurer's receipt of the notice?
Are all notifications to the insurer in writing?
Yes
No
Office procedures and controls
Does the Applicant have procedures or controls to ensure that all
Date/time sensitive items are entered into a central diary/suspense system?
Yes
No
Incoming mail is date stamped?
Yes
No
Employees correctly follow procedures?
Yes
No
Quotes and Binders are in writing and contain a description of coverage and restrictions?
Yes
No
Orders to bind are in writing from the insured or sub producer and state the coverage the bind
request is for?
Yes
No
Policies and endorsements comply with the insured's or sub producer's requests?
Yes
No
Requests for policy changes (endorsements) and reductions in coverage are in writing from the
insured or sub producer?
Yes
No
Requests for cancellation are in writing from the insured, sub producer or premium finance
company?
Yes
No
Policies that are renewed with less coverage than on the expiring policy, have a reduced coverage
statement acknowledging the coverage reduction that is signed by the insured or the sub
producer?
Yes
No
Does the Applicant place business as a retailer?
Yes
No
If yes, does the Applicant always
Use a comprehensive coverage checklist?
Yes
No
Get a written sign-off from the client if they decline to purchase recommended coverage?
Yes
No
Does the Applicant allow staff to sign an application on behalf of a client?
Yes
No
If yes, provide an explanation.
Does the Applicant check that all cancellation notices and nonrenewal notices are sent in compliance
with policy provisions and state statutory requirements?
Yes
No
Does the Applicant:
Require all sub agents and producers to have Errors and Omissions Liability Coverage?
Yes
No
Require a copy of all sub agents'/producers' licenses prior to binding any risk for them?
Yes
No
Have a system which ensures that its sub agents/producers are licensed and have in-force Errors
and Omissions Liability Coverage, each year?
Yes
No
Managing General Agents, Underwriting Managers and Program Administrators
1. Does the Applicant act as Managing General Agent ("MGA"), Underwriting Manager and/or
Program Administrator?
Yes
No
If no, skip to Claims/History section.
If yes, answer the following questions
2. Provide the following information for each organization that the Applicant has represented as an
MGA, Underwriting Manager or Program Administrator for the last five years.
Insurer
Domicile of Insurer
Number of Years
Represented
Annual total commission
and fees.
Number of Times
Audited per Year
QBPC-3002 FL (09-16) Page 6 of 10
3. In the last three years has any audit by an insurer stated that the Applicant
had exceeded its premium cap or underwriting authority?
Yes
No
Did not issue the correct policy wording and/or endorsements as mandated by the insurer?
Yes
No
If yes to either of the above questions, provide details and actions taken to amend procedures.
4. In the last three years, other than minor infractions, were all audits by insurers satisfactory?
Yes
No
If no, provide details.
5. In the last five years has any
MGA, Underwriting Manager or Program Administrator contract authority been canceled, revoked
or terminated?
Yes
No
Insurer added any restrictions to the Applicant's underwriting or claim handling authority?
Yes
No
If yes to either of the above questions, provide details.
6. What is the Applicant's maximum authority for the following
Binding Risks
Loss Control
Reinsurance Placement
$
$
$
Does the Applicant have authority for any insurer other than stated in 2. herein above?
Yes
No
If yes, provide details.
Total number of insurers for which the Applicant has authority of any kind
*Complete TPA / Claim Administrator Supplement
7. Provide the total number of producers that the Applicant has appointed as sub agents.
Has the Applicant delegated any underwriting, claim handling and/or any other authority to any
sub agent?
Yes
No
If yes,
Provide a detailed description.
Provide a copy of the contract with the insurer that authorizes the Applicant to delegate authority to
other organizations.
Claims/History
1. Limits of Liability: Indicate the limits of liability requested
Per Claim / Aggregate
$1,000,000 / $1,000,000
$3,000,000 / $3,000,000
$1,000,000 / $2,000,000
$3,000,000 / $5,000,000
$1,000,000 / $2,000,000
$4,000,000 / $4,000,000
$2,000,000 / $2,000,000
$5,000,000 / $5,000,000
$2,000,000 / $4,000,000
other
Deductible: Indicate the deductible requested
$5,000
$10,000
$15,000
higher –
specify
$
$20,000
$25,000
$50,000
The Company does not guarantee to offer any of the above limits and/or deductibles.
QBPC-3002 FL (09-16) Page 7 of 10
2. During the last five years, have there been any claims or proceedings arising out of professional
services against the Applicant or any of its principals, partners, officers, directors, trustees,
employees, managers or managing members or predecessors, subsidiaries, affiliates, and/or
against any other person or organization proposed for this insurance?
Yes
No
If yes, how many?
Attach a completed copy of our Supplemental Claim Form.
3. Is the Applicant and/or any of its principals, partners, officers, directors, trustees, employees,
managers or managing members or any person(s) or organization(s) proposed for this insurance
aware of any fact, circumstance, situation, incident or allegation of negligence or wrongdoing,
which might afford grounds for any claim such as would fall under the proposed insurance?
Yes
No
If yes, complete a copy of our Supplemental Claim Form.
4. Has the Applicant and/or any of its principals, partners, officers, directors, trustees, employees,
managers or managing members or any person(s) or organization(s) proposed for this insurance
ever been involved in or have knowledge of any pending or completed investigative or
administrative proceeding?
Yes
No
If yes, provide details.
5. Has the Applicant and/or any of its principals, partners, officers, directors, trustees, employees,
managers or managing members, predecessors, subsidiaries, affiliates, and/or any other person
or organization proposed for this insurance ever had its/his/her license suspended or revoked or
has its/his/her license ever been forfeited or ever been investigated or disciplined by a state
insurance department, federal agency, regulatory agency or professional review board?
Yes
No
If yes, provide details on a separate sheet.
6. Has any insurer cancelled, rescinded, nonrenewed or declined any similar insurance for the
Applicant, its predecessors, subsidiaries, affiliates and/or for any other person or organization
proposed for this insurance in the last five years?
Yes
No
If yes, attach a copy of such insurer’s notice.
7. Errors and Omissions Liability Insurance for the last five years
Policy Period
Insurer
Limits of Liability
Deductible
Retro Date
Premium
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 Claims/History section, questions 2., 3., 4.
and 5. 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.
QBPC-3002 FL (09-16) Page 8 of 10
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.
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 therefrom
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.”
QBPC-3002 FL (09-16) Page 9 of 10
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 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.”
QBPC-3002 FL (09-16) Page 10 of 10
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 60 days of the proposed effective date.
Signatures
Applicant's name
Title (Officer, partner, etc.)
Applicant’s signature
Date
______________________________________________
Insurance Agent Name
License Number
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and Omissions Liability Insurance INSURANCE CORPORATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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