INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY POLICY

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1 INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY POLICY NOTICE: The insurance coverage for which you are applying is written on a claims-made and reported policy form. Subject to policy provisions, this insurance will apply only to claims that are first made against you and reported to the Company while the policy is in force. 1. Applicant Name: Physical Address: City: County: State: Zip Code: Contact Name: Address: Website Address: Contact Phone Number: Fax Number: Mailing Address (if different from above): City: County: State: Zip Code: Dun & Bradstreet Identification Number 2. Additional Business Locations: (attach a separate sheet if necessary). N/A Name Street Address City County State Zip Code % of Revenue If there are additional locations, are all locations owned and under the direct control of the applicant? Yes No N/A If no, attach an explanation Are all locations managed using a common set of procedures? Yes No N/A 3. Applicant Ownership: Individual Partnership LLC/LLP Corporation Other: 4. a) Year Agency established: (if less than 3 years, attach resumes for all agency staff) b) Year current Owner assumed management: c) Number of years owner licensed as an agent as a broker d) Total staff size including Officers, owners, Principals, CSR s, etc. (assign an individual to one category only) If multiple staff, provides years of experience for each in remarks: Licensed Owners, Officers, Shareholders, Members and Partners Licensed Producers / Sales Staff Licensed Independent Contractors Other Licensed Staff Non-Licensed Staff Total # of Full-Time # of Part-Time Staff Yrs of Ins Experience 5. List the names of Licensed Owners, Officers, and Shareholders, Members and Partners and years of insurance experience. Individuals Name Relationship to Agency Insurance Designations if any % of Ownership if any Yrs of Ins Experience If more than 3, use the Remarks Section to provide the same detail on the additional individuals Page 1 of 9 10/26/2011

2 6. List the states where the Applicant and all Producers are licensed and percentage of total agency business placed in each state: / % / % / % / % / % / % / % / % / % (Use an additional sheet if necessary) 7. Is the Applicant controlled, owned, affiliated or associated with any other business entity? Yes No If yes, please provide detail in the Remarks Section or on a separate sheet 8. Does any entity(s) have a 10% or greater interest in the applicant or in any subsidiary or affiliate of the applicant? Yes No 9. During the past five years has the Applicant: a) Been controlled, owned, affiliated or associated with any firm, corporation or company? Yes No b) Changed names: Yes No c) Merged, Acquired or Consolidated with another firm: Yes No d) Purchased another agency s book of business (partial or total): Yes No e) Reorganized or entered into an arrangement with creditors under state or federal law: Yes No f) Entered into an association with a Cluster: Yes No g) Owned in whole or in part, managed or operated Captive Insurance Company? Yes No Risk Purchasing Group? Yes No Risk Retention Group? Yes No Self Insurance Program? Yes No Multiple Employer Trusts (MET) or Multiple Employer Welfare Arrangements (MEWA)? Yes No h. Placed coverage for risks involved in petroleum exploration and extraction, mineral exploration and mining, hazardous waste operations with significant pollution exposures? Yes No i. Specialized in any programs or classes of business? Yes No (If you answer yes to any part of Question 7, attach an applicable supplement or a detailed explanation) and if YES to item "i", the applicant must include the name of the program(s); the name of the insurer(s); the extent of the coverage provided by the insurer(s); the name and address of the administrator; any administrative duties performed by the applicant; and appropriate financial information, if applicable. You must also provide a copy of the promotional literature FORMER CAPTIVE AGENT S: USE ONLY NON-CAPTIVE PREMIUM & COMMISSIONS FOR Q. #10 & Please provide (estimate 12 months of business if this is a new firm): a. Total last 12 months P&C Gross Premiums Written $: b. Total last 12 months Gross P&C Commission Income $ c. Total Gross & Net WHOLESALE / MGA Commission Income $ Gross: $ Net: d. Total Gross Life, A&H Commissions $ e. Total income derived from OTHER INSURANCE RELATED ACTIVITIES. Please describe other insurance activities $ Page 2 of 9 10/26/2011

3 11. Breakdown of Applicant s business: (Total Commercial, Personal, and Life/Accident/Health should equal the total in question 10 on the prior page) COMMERCIAL LINES PREMIUM VOLUME COMMISSION INCOME % OF TOTAL Auto Non Standard Auto Standard Aviation Bonds-All Other Bonds-Surety CGL Crop Energy/Pollution/Environmental Farm Owners & Livestock Mortality Fire Non-standard Fire Standard Inland Marine Liquor Liability Long Haul Trucking Medical Malpractice Ocean/Wet Marine Other (Specify) Professional/Management Liability Reinsurance SMP/BOP/PKG Umbrella Excess Workers Comp TOTAL COMMERCIAL LINES & BROKER FEES PERSONAL LINES PREMIUM VOLUME COMMISSION INCOME % OF TOTAL Auto Non-standard Assigned Risk Auto Standard Fire Homeowners Standard Fire Nonstandard Other (Specify) Pleasure Boats Umbrella TOTAL PERSONAL LINES & BROKER FEES LIFE, ACCIDENT, HEALTH& DISABILITY* PREMIUM VOLUME COMMISSION INCOME % OF TOTAL A&H Individual & Group Annuities Fixed Life Individual & Group TOTAL LIFE, ACCIDENT, HEALTH, DISABILITY & BROKER FEES Annuities Variable Life - Variable Mutual Funds Other (Specify) FINANCIAL PRODUCTS* COMMISSION INCOME % OF TOTAL Securities TOTAL ALL FINANCIAL PRODUCTS *If more than 20%, please complete the L, A & H Supplement or provide full details on a separate sheet. **If any Aviation or Crop premium, please complete Aviation or Crop Supplement or provide full details on a separate sheet. Page 3 of 9 10/26/2011

4 12. What percentage of your written premium is: Retail (Business sold directly to Insured s) % Wholesale (Business placed for other agents)* % MGA (Business for which you have underwriting authority)* % Cluster or Carrier Service Center (Circle which or both if applicable)* % (*) indicates that a Supplemental Application must be completed. MUST TOTAL 100% % of your agency placed in State controlled Pools (Wind, Flood, Earthquake, Fire, Auto) % What percent of your agency s premium volume is received from outside brokers or wholesalers? % Please advise the type of business accepted, if written contracts with hold harmless agreements are used and whether you require these agents to carry E&O insurance in the Remarks Section. 13. Show your five largest carriers/companies and the percent of business placed with each: CARRIER COMPANY % OF TOTAL PREMIUM AGENCY CONTRACT ON A DIRECT BASIS? 1. Yes No 2. Yes No 3. Yes No 4. Yes No 5. Yes No ADMITTED OR NON- ADMITTED MAJOR LINES PLACED # OF YR(S) A.M. BEST RATING 14. Estimate the amount of business the agency places with carriers that are rated less than B+ or are not rated: % a. Please name each carrier with less than a B+ rating, including premium volume and type(s) of coverage in the Remarks Section b. If greater than 25% of your agency income, what procedures do you have in place to advise the potential insured: N/A c. Is there a procedure for checking insurance carrier s financial rating? Yes No If yes, what frequency? d. What minimum financial standard do you require for your insurance companies? e. In the past 3 years, has any carrier (or other risk bearing entity) which your agency used become insolvent, bankrupt, put into rehabilitation/receivership, or otherwise become unable to meet its duties to insured s? * Yes No *Please explain Yes responses in the Remarks Section. Page 4 of 9 10/26/2011

5 15. List insurance companies whose licensed employees provide customer service for your in-force clients N/A CARRIER COMPANY PREMIUM IN PLAN AGENCY HELD HARMLESS? COMMERCIAL OR PERSONAL LINES DO YOU PAY A FEE TO THE INSURANCE COMPANY FOR THIS SERVICE? 1. Yes No CL PL Yes No 2. Yes No CL PL Yes No 3. Yes No CL PL Yes No 16. List carriers with whom the Applicant (or predecessors) contract have been terminated within the last five years: COMPANY NAME: BRIEF DESCRIPTION: 17. Estimate the amount of business placed on a direct-bill basis: % 18. What percent of the Applicant s personnel has professional designations? % 19. What percent of Applicant s office staff has attended a sponsored insurance continuing education course or seminar in the last 12 months: % 20. If you are the sole agent at the applicant firm, please give name and contact information for the licensed agent who will handle your business in the event of your incapacitation or absence: 21. Does the applicant or any agency, owner, director, officer, partner, principal, employee or contractor perform any of the following activities? (If yes, attach resume, promotional material and sample contract. Coverage may be excluded under the policy). Reinsurance Intermediary Third Party Administrator Claim Adjustment Services and or Draft Authority Inspection, Risk management/loss control Investment, Securities Advisor Prepaid Legal Services Policy Issuance YES NO INCOME YES NO INCOME Real Estate Appraiser Real Estate Sales Actuarial Services Tax Advisor Premium finance for Non-Agency Clients Other Detail Other in the Remarks section Page 5 of 9 10/26/2011

6 OFFICE PROCEDURE 22. Does your agency have the following written procedures in place to assure consistency in the following Office Procedures? a. Does Applicant have written documentation detailing office procedures for use by all staff? Yes No b. Are internal procedure audits conducted periodically? Yes No c. Do you document when changing carrier s providing coverage? Yes No d. Do your procedures in place to ensure written confirmation of coverage requested, declined and accepted by the insured (i.e. Checklists)?document when an insured refuses coverage? Yes No e. Do you document your disclosure to the insured when a carrier declines to offer a particular coverage? Yes No f. Does the agency have procedures in place to ensure written documentation of policy limitations including but not limited to; wind deductibles, hurricane deductibles and earthquake deductibles? Yes No g. Do you have a written procedure for reporting claims ( if you handle claims directly) N/A Yes No h. How long are applicant records maintained? years i. Is there a procedure for surplus lines tax filings? N/A Yes No j. Does Applicant utilize an (check all that are applicable): a. Automated Computer System b. Automated Accounting System c. Automated Agency Management System d. Online Carrier System If yes, is there an automated backup procedure for all client records including accounting? Yes No k. Is there a procedure for documenting all phone conversations? Yes No l. Is an expiration list maintained? Yes No m. Is all correspondence marked with a received or sent date? Yes No n. Does the Applicant use a diary, suspense or follow-up system? Yes No o. Does the Applicant require requests to bind or cancel coverage be in writing? Yes No p. Are all applications, policies and endorsements checked for accuracy? Yes No q. Are files marked to ensure certificate holders are notified of cancellation or material changes? Yes No r. Are copies of binders mailed to the insured and/or the company within specified guidelines? Yes No s. Is a written request required from any Insured who desires to change or cancel coverage? Yes No t. Do you maintain a premium trust account separate from your agency operations and personal accounts? Yes No u. Does the applicant offer purchasers of automobile policies (i.e. personal auto and commercial vehicles) the option of increasing Uninsured Motorists limits? Yes No If yes, are the procedures in place to document this communication? Yes No If No to any of the above, please indicate reason(s) in the Remarks Section. v. Does the Applicant use power of attorney to represent the insured? Yes No 23. Check which of these describes your agency s E&O risk management education during the past two years: 5 10% of staff attended a course 11 50% of staff attended a course More than 50% attended a course Other (describe in Remarks) None a. Has the agency had an Errors and Omissions Survey and or Audit? Yes No i. If YES, Were all recommendations implemented? Yes No ii. Date of Audit 24. Check which Professional Designations are held: None CIC CPCU CLU CISR Other a. Check which organization memberships are held: None IBA West IIA PIA Other Page 6 of 9 10/26/2011

7 25. List prior insurance carried during the past 5 years: Check if no coverage in place Policy Period Carrier Limits Deductible Premium Retroactive Date 26. If you previously were a Captive Agent, what is the date of your Agency Appointment with the carrier? a. Did you maintain Errors and Omission Coverage continuously while a Captive Agent? b. What is date did your contract terminate with the Captive carrier? 27. Has applicant ever purchased an extended reporting period endorsement? Yes No 28. During the past 5 years, has the Applicant, any other predecessor in business, past or present owner, director, officer, partner, principal, employee or contractor: a. Been the subject of a complaint filed and/or disciplinary action by any insurance regulatory authority? Yes No If yes, attach an explanation b. Had any policy or application for similar insurance declined, cancelled, rescinded or refused renewal? Yes No If yes, attach an explanation c. Had any claim(s) made or suit(s) brought against them? Yes No If yes, complete claim supplement for each claim and attach prior carrier loss run d. Become aware of any fact, circumstance or situation which may result in a claim being made? Yes No If yes, please complete a claim supplement. 29. If you answered yes to any part of question 28, have they been reported to your Errors & Omissions carrier? Yes No IMPORTANT NOTE: The applicant s disclosure of claim information does not indicate nor imply, in any way, that any act or omission is covered by this policy. In addition, circumstances or incidents that might reasonably be expected to be the basis of a claim MUST be reported to the applicant s current insurer before the claim reporting period expires. Policy Coverage Desired 30. Limits of Liability: Per Claim Policy Aggregate a. Deductible: Loss Only Loss and Claims Expenses b. Desired Policy Effective Date: / / c. Current Policy Retroactive Date No coverage currently in force, Retroactive Date will be inception date. Yes No d. Do you want coverage for the sale of Mutual Funds? Yes No If yes, provide the broker/deal information below: Broker / Dealer Name Compliance Officers Name License Number Page 7 of 9 10/26/2011

8 31. Is coverage desired for all Independent Contractors? Yes No (If Yes, please provide names(s) and percentage of Premium Volume in Remarks Section) 32. Does your agency require Real Estate E & O Coverage? Yes No If Yes, please complete the Real Estate Supplement or provide full details on a separate sheet. Remarks, please note the question number you are explaining below, attach a separate sheet on your letterhead if needed. Item Checklist Claims Supplemental Cluster Supplemental (if appointed by a Cluster Agency) Copy of current policy declarations page showing policy Retroactive Date (If currently insured) Independent Contractors Supplemental L& H Supplemental (if greater than 20% of agency business) Loss history from prior carriers for the last 5 years or operational period if less than 5 years if insured No Loss Letter (if not currently insured) Real Estate Supplemental Resume if less than 3 years agency ownership experience Fraud Warning: 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. Arkansas, Louisiana, New Mexico and West Virginia Fraud Warning: 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. Colorado Fraud Warning: 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 benefits, and/or civil damages. In Colorado, 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 or regulatory agencies. D.C. Fraud 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. Florida Fraud Warning: Any person who knowingly and with Page 8 of 9 10/26/2011

9 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. Maryland Fraud Warning: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota Fraud Warning: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New York Fraud Warning: 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 Fraud Warning: Any person who, with the 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. Oregon Fraud Warning: 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 may be a crime. Pennsylvania Fraud Warning: 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 Fraud Warning: 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. Maine, Virginia and Washington Fraud Warning: 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 and a denial of insurance benefits.. NOTICE TO APPLICANT PLEASE READ CAREFULLY BEFORE SIGNING THE APPLICANT AND AGENCY ACCEPTS NOTICE THAT ANY POLICY ISSUED WILL APPLY ON A CLAIMS-MADE BASIS. The undersigned is authorized by and acting on behalf of the Applicant and represents that all statements and particulars herein are true, complete and accurate and that there has been no suppression or misstatements of fact and agrees that this application shall be the basis of coverage. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT THEY ARE REQUIRED TO PROVIDE WRITTEN NOTIFICATION TO THE COMPANY OR ANY CHANGES TO THIS APPLICATION THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE. THE APPLICATION MUST BE SIGNED BY AN ACTIVE OWNER, PARTNER, PRINCIPAL, OFFICER, OR MEMBER OF THE APPLICANT. Print Name Title Signature Date Page 9 of 9 10/26/2011

10 INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY POLICY Supplement Claim Information Form Applicant s Instructions: A separate supplement should be completed for each claim or potential claim experienced in the last five (5) years; if the space allotted is not adequate, provide details as a separate attachment, complete, sign and date the supplement in ink. 1. Applicant s Name: 2. Name of Agency that reported claim (if different than above): 3. Name of the Claimant: 4. Date of alleged error: (MM/DD/YYYY) Date claim Made: (MM/DD/YYYY) 5. Date claim reported to E&O Carrier: (MM/DD/YYYY) 6. Describe the claim or incident (include the type of coverage involved, allegations asserted and agency response): 7. Status of Claim (check one only): Incident only in Suit Open Closed If claim is open or in suite, answer the following: 8. Claimant s settlement demand: $ Paid Losses to date: $ Defendant s last offer for settlement: $ Paid Expenses to date: $ 9. Brief status of current activity: If claim is closed, answer the following: 10. Total expenses paid: $ Deductible Applicant paid: $ Total losses or damages paid: $ Date Claim closed: (MM/DD/YYYY) 11. What steps have been taken to prevent a recurrence or similar claims? I understand that the information submitted in this supplement becomes a part of my E&O application and is subject to the same warranties and conditions. Print Name Title Signature Date Supplement must be signed by an owner, officer, partner or principal of the Applicant. IAP APP CLAIM Page 1 of 1 2/2/2013

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