APPLICATION FORM (THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY)
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1 INSTRUCTIONS 1. Please answer all questions, leave no blank spaces. 2. If space is insufficient to answer fully any questions, please attach separate sheet. 3. Application must be signed and dated by owner, partner or officer. INSURANCE BROKER S PROFESSIONAL INDEMNITY INSURANCE APPLICATION FORM (THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY) NOTE: In applying for the coverage, the applicant understands that in the event of an insured loss, the limit of liability and deductible shall be inclusive of the loss payment and the claim expenses as defined in the policy. 1. NAME OF FIRM AND ADDRESS OF THE HEAD OFFICE: ADDRESS(ES) OF BRANCH OFFICES: NAMES AND ADDRESSES OF PARENT AND SUBSIDIARY OPERATIONS, AND % OWNED: THE APPLICANT IS: INDIVIDUAL... PARTNER... CORPORATION... OTHER (DESCRIBE)... DATE ESTABLISHED... IF ESTABLISHED WITHIN THE LAST THREE YEARS, PLEASE PROVIDE DETAILS OF PREVIOUS INSURANCE EXPERIENCE OF PRINCIPALS. 5. DURING THE PAST FIVE YEARS: (a) HAS THE NAME OF THE FIRM BEEN CHANGED? IF YES PLEASE GIVE DETAILS......
2 (b) HAS ANY OTHER FIRM BEEN PURCHASED, MERGED OR CONSOLIDATED WITH THE APPLICANT? IF YES, PLEASE GIVE DETAILS WHAT IS THE TOTAL NUMBER OF PARTNERS, STAFF AND OFFICE BROKERS? (a) (b) (c) TOTAL NUMBER OF PARTNERS (INCLUDING THE SIGNATORY ON THE PROPOSAL FORM)... ALL STAFF, SUCH AS CLERKS, TYPISTS, TELEPHONE OPERATORS, ETC.... SOLICITORS AND OFFICE BROKERS REMUNERATED ON A COMMISSION BASIS (TO BE NAMED ON A SEPARATE SCHEDULE) IS THE FIRM LICENSED (WHERE NECESSARY) OR DOING BUSINESS AS: (a) INSURANCE BROKER (b) INSURANCE AGENT (c) GENERAL INSURANCE AGENT (d) MANAGING GENERAL AGENT (e) UNDERWRITER FOR A POOL OF COMPANIES (f) INSURANCE CONSULTING/ADVISING IF THE ANSWER TO 7.(d) OR (e) IS YES, PLEASE COMPLETE THE ATTACHED SUPPLEMENTARY QUESTIONNAIRE. 8. IS APPLICANT INVOLVED IN ANY OF THE FOLLOWING ACTIVITIES, IF YES PLEASE SHOW PERCENTAGE OF TOTAL REVENUE RECEIVED FROM EACH ACTIVITY: (a) REAL ESTATE...% (b) MUTUAL FUNDS...% (c) PREMIUM FINANCING...% (d) CLAIMS ADJUSTING...% (e) LOSS PREVENTION ENGINEERING...% (f) THIRD PARTY ADMINISTRATOR...% (g) LAW PRACTICE...% (h) IS THE APPLICANT ENGAGED IN ANY ACTIVITIES OTHER THAN THOSE ALREADY LISTED IN QUESTIONS 7 AND 8?...% IF YES PLEASE LIST ADDITIONAL ACTIVITIES......
3 PLEASE NOTE THAT NO COVERAGE IS GRANTED FOR THESE ACTIVITIES UNLESS SPECIFICALLY AGREED BY ENDORSEMENT TO THE POLICY. 9. WHAT IS THE ANNUAL PERCENTAGE BREAKDOWN BY LINE OF BUSINESS OF THE APPLICANT S ANNUAL PREMIUM INCOME? % OF TOTAL (a) FIRE & E.C. (COMMERCIAL LINES)... (b) SUBSTANDARD FIRE... (c) PACKAGE POLICIES... (d) HOMEOWNERS... (e) AUTO STANDARD... (f) AUTO NON STANDARD... (g) MEDICAL MALPRACTICE... (h) PROFESSIONAL LIABILITY, D&O, E&O... (i) GENERAL/UMBRELLA/EXCESS LIABILITY... (j) WORKERS COMPENSATION... (k) LIVESTOCK MORTALITY/BLOODSTOCK... (l) FLOOD... (m) LONG HAUL TRUCKING... (n) CROP INSURANCE... (o) JEWELLERS BLOCK... (p) MARINE (PLEASE SPECIFY TYPE)... (q) AVIATION (PLEASE SPECIFY TYPE)... (r) LIFE (PLEASE SPECIFY TYPE)... (s) ACCIDENT & HEALTH (PLEASE SPECIFY TYPE)... (t) POLLUTION LIABILITY... (u) BONDS... (v) REINSURANCE... (w) OTHER (PLEASE SPECIFY) DOES THE APPLICANT PLACE BUSINESS WITH LLOYD S UNDERWRITERS, IF YES PLEASE GIVE THE APPROXIMATE PERCENTAGE OF YOUR TOTAL COMMISSION/BROKERAGE DERVIED THEREFROM: (a) DIRECTLY THROUGH ANY FIRM OF LLOYD S BRO KERS IN LONDON?...% (b) INDIRECTLY THROUGH THE INTERMEDIARY OF ANOTHER NORTH AMERICAN AGENT OR BROKER?...% 11. WHAT PERCENTAGE OF THE APPLICANT S BUSINESS IS: (a) (b) RECEIVED DIRECT FROM INSUREDS? ACCEPTED FROM OTHER PRODUCERS?
4 12. DURING THE APPLICANT S LAST FINANCIAL YEAR WHAT WAS: (a) TOTAL PREMIUM INCOME... (b) TOTAL COMMISSION OR BROKERAGE... (c) INSURANCE CONSULTING FEES... (d) TOTAL FEES DERIVED FROM OTHER ACTIVITIES (PLEASE LIST) LIST THE TOP FOUR INSURANCE COMPANIES BY PREMIUM INCOME WITH WHICH YOU PLACE BUSINESS AND SHOW THE DOLLAR VOLUME FOR EACH: INSURANCE CO ADMITTED? VOLUME PLACED? CURRENT BESTS INSURANCE RATING (a) DOES APPLICANT DELEGATE BINDING AUTHORITY TO SUB- PRODUCERS? (b) DOES APPLICANT ADJUST CLAIMS? (c) DOES APPLICANT HAVE AUTHORITY TO DENY CLAIMS (e) DOES APPLICANT NEGOTIATE/PURCHASE REINSURANCE? 15. HOW ARE STAFF MEMBERS KEPT INFORMED OF CHANGES IN LEGISLATION THAT MIGHT AFFECT YOUR FIRM, CLIENTS OR CARRIERS? DO YOU HAVE PROCEDURES TO RECORD AND DOCUMENT FOR THE FILE ALL BUSINESS RELATED TELEPHONE CONVERSATIONS AND REQUIRE EMPLOYEES TO FOLLOW THOSE PROCEDURES? 17. ARE ALL DECLINATIONS OF COVERAGE CONFIRMED IN WRITING? 18. DO YOU OBTAIN INSTRUCTIONS IN WRITING FROM CUSTOMERS WHO WANT THEIR INSURANCE COVERAGE REDUCED OR ELIMINATED?
5 19. ARE CUSTOMERS ADVISED IN WRITING WHENEVER INSURANCE COVERAGE CANNOT BE BOUND IMMEDIATELY OR WHEN SPECIAL RESTRICTIONS AND/OR ENDORSEMENTS APPLY? 20. PLEASE GIVE FULL PARTICULARS OF ALL SIMILAR INSURANCES DURING THE PAST FIVE YEARS: INSURER AMOUNT OF POLICY DEDUCTIBLE PERIOD PREMIUM 21. HAS ANY APPLICATION FOR INSURANCE MADE ON BEHALF OF THE FIRM OR ANY OF THE PRESENT PARTNERS OR, TO THE KNOWLEDGE OF THE FIRM, ON BEHALF OF THEIR PREDECESSORS IN BUSINESS, EVER BEEN DECLINED OR HAS ANY SUCH INSURANCE EVER BEEN CANCELLED OR RENEWAL REFUSED? IF YES, PLEASE GIVE FULL PARTICULARS ON A SEPARATE SHEET. 22. HAS THE APPLICANT OR ANY PARTNER OR EMPLOYEE OF ANY APPLICANT PROPOSED FOR INSURANCE EVER BEEN SUBJECT TO DISCIPLINARY ACTION BY ANY STATE LICENSING AGENCY OR OTHER REGULATORY BODY? IF YES, PLEASE GIVE FULL PARTICULARS ON A SEPARATE SHEET. 23. HAVE ANY CLAIMS BEEN MADE DURING THE PAST FIVE YEARS AGAINST THE FIRM, THEIR PREDECESSORS IN BUSINESS OR ANY OF THE PRESENT PARTNERS OR, TO THE KNOWLEDGE OF THE FIRM, AGAINST ANY PAST PARTNERS? IF YES PLEASE GIVE FULL PARTICULARS ON A SEPARATE SHEET. 24. IS THE FIRM AWARE, AFTER ENQUIRY, OF ANY CIRCUMSTANCES WHICH MAY RESULT IN ANY CLAIMS BEING MADE AGAINST THE FIRM, THEIR PREDECESSORS IN BUSINESS OR ANY OF THE PRESENT OR PAST PARTNERS? IF YES, PLEASE GIVE FULL PARTICULARS ON A SEPERATE SHEET. 25. (a) WHAT LIMIT OF INDEMNITY IS REQUIRED?... (b) WHAT AMOUNT OF DEDUCTIBLE IS REQUIRED?...
6 NOTE: IF THE APPLICANT DOES NOT UNDERSTAND ANY PART OF THE PROFESSIONAL LIABILITY COVERAGE THEN THE APPLICANT SHOULD CONTACT THEIR RELEVANT INSURANCE BROKER/ADVISOR AND NOT SIGN THE APPLICATION. I/WE HEREBY DECLARE THAT THE ATTACHED STATEMENTS AND PARTICULARS ARE IN ALL RESPECTS TRUE AND ARE MATERIAL TO THE ISSUANCE OF INSURANCE HEREIN AND THAT I/WE HAVE NOT OMITTED OR SUPPRESSED OR MIS-STATED ANY FACTS AND I/WE AGREE THAT THIS PROPOSAL FORM SHALL BE THE BASIS OF THE CONTRACT AND SHALL WE BE DEEMED A PART OF THE POLICY AS IF ANNEXED THERETO. SIGNATURE OF THIS FORM DOES NOT BIND THE FIRM OR THE UNDERWRITERS TO COMPLETE THE INSURANCE. NAME OF FIRM... BY... Owner, Partner or Officer (Must be signed) DATE... TITLE...
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