INSURANCE AGENTS APPLICATION FORM

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Conrad Cameron
8 years ago
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1 INSURANCE AGENTS APPLICATION FORM Last Name First Name Title Mailing Address Town/City State Zip Phone Address Do you have a current professional liability policy in place? If, what is the Retro-active date of your current policy? What date was your agency established? Your Agency does business as a Corporation Partnership Sole Proprietor LLC Other What is the gross premium written in the last 12 months? (if you are a new agency, please give your estimate of your revenue in the coming 12 months) $ Do you place business with any carriers that are not rated by a rating agency such as AM Best? Do you write any business in any of the following lines of coverage? Surety bonds, Aviation, Crops, Long haul trucking, Physicians/Hospital liability, Professional liability, Third party administration, Earthquake, Livestock mortality. Do you derive any income from non-insurance broker/agent/retailer related activities? e.g. TPA services, Reinsurance intermediary, Mutual funds sales, Annuities sales. Have you, or any of your employees, ever been subject to an investigation by a state regulatory agency, administrative agency and/or an insurance department investigation or inquiry or disciplinary investigation or proceeding in any way? Have you, or any of your employees, ever had a license revoked, suspended, or been fined or disciplined by any state or regulatory department? During the last five years, has any claim or notice of claim been made or suit brought against you, your predecessor(s) in business, or any of the present of former owners, partners, officers, directors, employees or independent contractors? Are you, your predecessor(s) in business, or any of the present or former owners, partners, officers, directors, employees or independent contractors aware of any fact, circumstance, situation, allegation, contention or incident which may result in a claim being made against you, your predecessor(s) in business, or any of the present or former owners, partners, officers, directors, employees or independent contractors?

Your Agency does business as a Corporation Partnership Sole Proprietor LLC Other What is the gross premium written in the last 12 months?

2 In the last 5 years have there been any changes in management structure, including additions, or deletions of any principals, owners, managers or brokers? In the last 5 years, has the Agency s name been changed or has any business purchased, merged or been consolidated with the Agency? When was the Principal of your agency first licensed as a Property/Casualty Agent or Broker? When was the Principal of your agency first licensed as a Life/Health Agent or Broker? N/A N/A Please give details of your agency personnel (each individual should be classified in only one category) # Full time # Part time Owners, Officers and /or Partners Licensed employee solicitors, brokers and /or agents CSRs Other employees (including clerical) Exclusive non-employee Producers n-exclusive non-employee Producers Please list the top 5 insurance companies with whom you do business. (If you are a new business, please list the carriers with whom you plan to do business and your estimate of the premium volume) Insurance Company Annual premium volume Current A M Best Rating

When was the Principal of your agency first licensed as a Property/Casualty Agent or Broker? When was the Principal of your agency first licensed as a Life/Health Agent or Broker?

3 What percentage of business do you place with: Admitted carriers? % (If you are a new business please give your estimate of the percentages you anticipate) n-admitted carriers? % Please provide, for the current 12 month period, your total premium volume deriving from the following areas: (If you are a new business please give your estimate of the premium volumes you anticipate writing) Personal lines Personal auto $ Homeowners $ Personal Umbrella $ Mobile homes $ Please specify: Commercial lines Long Haul Trucking $ Livestock Mortality $ General Liability $ Wet Marine $ Workers compensation $ Third Party Administration $ Commercial Auto Liability $ BOPs $ Inland Marine $ Aviation $ Surety Bonds $ Crop / Hail $ Bonds other than surety bonds $ Pollution $ Umbrella Excess $ Physicians / Hospital Liability $ DIC, Earthquake $ Professional Liability $ Commercial Multi Peril (including Commercial Property) $ Please specify Life, Accident and Health Individual Life / Health $ Group Life / Health $ Annuities (fixed) $ Annuities (variable) $ Please specify:

anticipate writing) Personal lines Personal auto $ Homeowners $ Personal Umbrella $ Mobile homes $ Please specify: Commercial lines Long Haul Trucking $ Livestock Mortality $ General Liability $ Wet

4 Current 12 months Estimated next 12 months Total Property & Casualty gross written premium $ $ Total Life Accident and Health gross written premium $ $ Total Life Accident and Health commission $ $ What percentage of your agency income derives from Commercial Lines? % What percentage of your agency income derives from Personal Lines? % Do you derive any income from the following areas? Mutual funds % MGA / MGU Program Administrator % Third Party Administrator % HR Services % Reinsurance Intermediary Premium Financing % % Consultant (for fees) % Loss Control Engineer / Risk management consultant for fees % Business as a surplus lines broker / wholesaler broker (business placed by your agency on behalf of other non-employee agents or brokers) % Have you ever had any association with a cluster or franchise business? Does your agency ever give verbal binders of coverage? Does your agency have a diary/suspense/notification/calendaring system? Are all applications, policies and endorsements checked for accuracy? Does your agency check all notices of cancellation to assure compliance with policy cancellation conditions and statutory requirements? Is there a back-up procedure for when your agency s personnel are away from the office?

Mutual funds % MGA / MGU Program Administrator % Third Party Administrator % HR Services % Reinsurance Intermediary Premium Financing % % Consultant (for fees) % Loss Control Engineer / Risk

5 Does your agency offer flood / wind / earthquake coverage? N/A If your customer declines flood / wind / earthquake coverage, do you ask them to sign a statement to that effect? Does your agency monitor solvency and financial condition of the Insurers with which your agency places business? N/A Does your agency have a procedure to verify that its principals are appropriately licensed in all states in which it is doing business? Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. Signature Date Please return to: InsuranceBee Inc

Does your agency monitor solvency and financial condition of the Insurers with which your agency places business?

INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS APPLICATION

APPLICANT S INFORMATION: INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS APPLICATION Legal Name of Entity: Business Address: County: Web Address: Date Entity Established: Number of Locations: Date Present