Insurance Broker’s Professional Liability Insurance Application

Insurance Broker’s Professional Liability Insurance Application

(This is an application for a claims made policy.)

INSTRUCTIONS

1 Application must be complete and legible. Please attach additional sheets as needed. 2 If answer to any question is ‘0’ or ‘NONE’ this must be indicated. Failure to do so may result in a rejected application. 3 For New Business/Start up agency—if business in operation LESS than 3 years, you must forward a resume of prior insurance and management experience with the application. You must make premium and commission projections (N/A, new business, TBD are not acceptable responses).

Before insurance is provided, it may be subject to a fully completed and signed Company E&O application form. The insurance is subject to the terms and conditions of the policy if issued.

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8 Revenue: (If this is a new agency, please estimate the written premium and commissions for the next 12 months)

9 Current E&O Carrier Expiring Premium

Expiring Limit Expiring Deductible

Expiration Date Retro Date

10 Office Procedures:

a Date stamp incoming mail? Yes No

b Maintain a diary/suspense system? Yes No

c Document all business related telephone conversations? Yes No

d Delegate any binding authority? Yes No

e Adjust claims? Yes No

f Have authority to deny claims? Yes No

g Negotiate/purchase Reinsurance? Yes No

11 Does the applicant derive revenue from any other business activities (including but not limited to loss prevention, mutual funds, real estate or law practice)? Yes No
If “Yes”, explain in detail and provide amount.

12 During the past five years:

a Has the name of the firm been changed? Yes No

b Has any other firm been purchased, merged or consolidated with the applicant? Yes No

c Does the applicant participate in any cluster groups or agency networks such as Superior Access, SIAA, Iroquois Group, AgentSecure, The Insurance Noodle, Smartchoice, etc.? Yes No

13 Is the applicant employed by or in any way associated with any other ins. agency? (if yes explain) Yes No

14 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? Yes No

15 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? Yes No

16 Has the Applicant or any of its employees ever been subject to an investigation by a state regulatory agency or an insurance department investigation, inquiry, disciplinary investigation or proceeding in any way? Yes No

17 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? Yes No

18 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? Yes No

19 Has the agency ever paid an uninsured loss out of company funds? Yes No

If answered “Yes” to any question(s) 11 through 19 above, you MUST give full particulars on separate sheet.

20 Cyber Liability/Data Breach—Does the Applicant:

a Maintain anti-virus and malware prevention solutions on their computer systems? Yes No

b Update anti-virus and malware prevention software on regular intervals? Yes No

c Maintain firewalls on their computer systems? Yes No

d Maintain and implement an ongoing patch management process to ensure timely patching of their computer systems? Yes No

e Is the Applicant aware of any incidents of data breach that has occurred during the last five (5) years? Yes No

If “Yes”, explain in detail.

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This is an application for a claims made policy. Except as otherwise provided, the policy will cover only claims first made against the applicant and reported to the insurer during the policy period. Please note that in most policies the limit of liability available to pay damages shall be reduced and may be completely exhausted by payment of claims expenses. Damages and claims expenses shall be applied against the deductible.

I/we hereby declare that the above statements and declarations are true and that I/we have not suppressed or misstated any material facts. I/we agree that any misrepresentation or misstatement of material facts may void coverage under the proposed insurance. I/we agree that this application shall be the basis of the contract with the insurer and that coverage, if written, will be provided on a claims made basis. It is understood and agreed that completion of this application neither binds the insurer to provide coverage nor the applicant to purchase the insurance. I/we agree that if the information supplied on this application changes between the date the application is executed and the time the proposed insurance policy is bound or coverage commences, the applicant will immediately notify the carrier in writing of such changes. The carrier reserves its rights to modify or withdraw its proposal following such changes.

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