INSURANCE AGENTS AND BROKERS E & O 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

Name :
(exactly as shown on licence-attach copy of licence) :

D/B/A (if applicable): :
Individual Partnership Corporation

P.O.Box: :

E-Mail: :

Phone No :

Street Address: :

FAX No: :

City,State,Zip: :
(list additional locations on seperate sheet,if necessary) :

Requested Effective Date: :
3.list the following information and identify all owners,partners,officers,directors and licensees:(attach separate sheet if necessary)
NAME
RESIDENCE ADDRESS
DATE OF BIRTH
 TITLE SOCIAL SECURITY # YEARS INS.EXPERIENCE
4.Limit of Liability desired: $ each claim/aggregate Deductible: $ each claim
5.License Number(s): Date First Licensed: Date Firm Established
6.State Applicants Annual Premium Volume,Gross Commission and Policy / Broker Fee Income
Premiums
Commissions
Policy/Broker Fees

Last 12 Months: :

Est.next 12 Months: :
7.State the approximate breakdown of total annual volume for each column
7a.Transacting as:
7b.Lines of Business

Agent :
%

Commercial Fire & Inland Marine :
%

Broker :
%

Commercial General/Excess Liab :
%

Surplus Lines Broker :
%

Commercial Auto.Garage/Dealers:
%

Managing General Agent :
%

Professional Liability:
%

Underwriting Manager :
%

Workers Comp:
%

Program Manager :
%

Ocean Marine:
%

Fee Consultant :
%

Avaition :
%

Life Health :
%

Surety :
%

Agent/Broker :
%

Homeowners/Dwelling Fire :
%

Adjuster :
%

Personal Auto :
%

Appraiser :
%

Personal Floaters :
%

Financial Planner :
%

Life/Accident/Health/Group :
%

Reinsurance Broker :
%

Other(Explain) :
%

MUST TOTAL :

100% :

MUST TOTAL :

100% :

7c.Business Written Directly for your own insureds :
%

Business Accepted from Other agents and brokers :
%
Percentage of business which is direct billed by carriers Auto % Homeowners % Commercial % Other%
8a.Name all Companies the applicant represents under direct Agent or Broker Agreements
COMPANY
ADDRESS
DATE APPOINTED
 LINES OF BUSINESS VOLUME
8b.List General Agents,MGA'S ans Surplus Line Brokers with Whom you place business
NAME
LINES OF BUSINESS
COMPANIES USED
 VOLUME
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9.Have any Companies,General Agents or other markets withdrawn from your agency in the past three years?(If Yes,Explain)
Yes
No
10.Name all companies for which the applicant act as G.A,Managing general Agent Or Underwriting Manager
11.Specify the maximum limit(s) the applicant is authorised to bind: (In Amount)

Fire: :
$ (Amount)

Auto Physical Damage :
$(Amount)

General Liability :
$ (Amount)

Home Owners :
$(Amount)

Auto Liability :
$ (Amount)

Excess Liability :
$(Amount)
12a.Does agency specialise in writing any class of risk(Example: 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:
13a.NUMBER OF STAFF
FULL TIME
PART TIME
13a.NUMBER OF STAFF
FULL TIME
PART TIME
Principals
Agents/Brokers/Solicitors (Not listed as principals)
Service/Raters
Accounting/Book Keeping
Clerical/Filing
Independent Contractors(Not Salaried Employees)
Other
TOTAL
13b.Do persons responsible for the transaction of insurance speak and write English?
Yes
No
What other languages 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 of Automation vendor
14d.Name of software system and program
14e.Version
Date of Installation
14f.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 contuaning 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 5 years.If none,state NONE.
INSURANCE CO.
LIMITS OF LIABILITY
DEDUCTIBLE(IF ANY)
 PREMIUM INCEPTION M/D/Y EXPIRATION M/D/Y CLAIMS YES CLAIMS NO
Yes
No
Yes
No
Yes
No
Yes
No

16b.Retroactive date of current policy: :
17.Have any claim or suits been made during the last 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?(if yes,attach statement giving detail and status of each claim including dates,amount of claim,deductible,payments and open reserves.)
Yes
No
18.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
19.Has any application for insurance on behalf of the applicant or any of its predesessors inbusiness been declined or canceled,or renewal of such insurance been refused?
Yes
No
20.Has any applicant or any person or employee of any applicant proposed for insurance ever been subject to disciplinary action by any State licencing Agency or other regulatory body?
Yes
No
21.LIndicate all insurance Professional Association of which you are a member:
IIAA PIA American A Alliance WAIB AAMGA NAPSLO Other
22.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 occurence or event taking placer 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 acknowlodges and agrees that the submission and the insurer's receipt to such written report,prior to the inception of the policy applied for ,is a condition precedent to coverage.
23.The applicant accepys 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 demages resulting from any claim or claim expense,as that term is defined in the policy,alleged to have occured prior to the inception date of the policy unless the Underwriter shall agree to insure demages resulting from claim or claim expense alleged to have occured prior to the Inception Dated but after an agreed upon Retroactive date,and;
THE LIMITS OF LIABILITY STATED IN THE POLICY INCLUDE THE COSTS OF CLAIMS EXPENSE AND MAY BE REDUCED OR EXHAUSTED BY SUCH COSTS AND IN SUCH EVENTS THE UNDERWRITERS SHALL NOT BE LIABLE FOR THE COSTS OF CLAIMS EXPENSE FOR THE AMOUNT OF ANY JUDGEMENT OR SETELLMENT TO THE EXTEND THAT SUCH EXCEEDS THE LIMIT OF LIABILITY OF THE POLICY.IF THERE IS A DEDUCTIBLE AMOUNT SHOWNIN THE DECLARATIONS,CLAIMS EXPENSE COSTS INCURRED IN THE DEFENCE OF ANY CLAIM WILL BE APPLIED AGAINEST THE DEDUCTIBLE AMOUNT.
The applicant hereby authorizes the Underwriters,and/or their representatives by signing this application,to contact any prior insuror and obtain any details ,or prior loss information,or obtain any other information from any source including consumer credit information,which the underwriterd deem important in the underwriting of the insurance applied for by this application.
It is agreed that the signature to this form does not bind the Underwriters nor the applicant to complete this insurance.

Name Of Applicant :

Dated: :

Signature of owner,Partner,or President :

Title :

                                   
if there are additional documents to be submitted, please fax them to 954-430-4363. Thank you