You may fax your application to: (304)

(1)

You may fax your application to:

(304) 344-4492

However, all original applications should be mailed to the

address shown above. Coverage will not be bound

without receipt of an original application.

If you have any questions,

please call Valerie Toney at (800) 274-4298.

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Pennsylvania National Mutual Casualty Insurance Company Penn National Security Insurance Company P.O. Box 2361 Harrisburg, PA 17105-2361

INSURANCE AGENT’S COMMERCIAL - PERSONAL UMBRELLA

STATE RATES AND MINIMUM UNDERLYING LIMITS

ARKANSAS, KENTUCKY, MISSISSIPPI, WEST VIRGINIA

COMMERCIAL MINIMUM UNDERLYING LIMITS REQUIREMENTS

COMMERCIAL GENERAL LIABILITY

SIMPLIFIED ISO OCCURRENCE

OR CLAIMS-MADE FORM

$1,000,000 General.Aggregate

$1,000,000 Prod/Co Aggregate $500,000 Each Occurrence $500,000 Personal/Advertising $50,000 Fire Damage Limit $5,000 Med Expense Limit

BUSINESSOWNERS Staff Rated

Other than Staff Rated

$ 500,000 CSL

$1,000,000 CSL

ERRORS AND OMISSIONS Gross Commission Income

$ 0 – 500,000

$ 500,001 - $1,000,000

$1,000,001 - $1,500,000

$1,500,001 - $8,000,000

$1,000,000 Each Claim

$1,000,000 Aggregate

$1,000,000 Each Claim

$2,000,000 Aggregate

$1,000,000 Each Claim

$3,000,000 Aggregate

$2,000,000 Each Claim

$4,000,000 Aggregate COMMERCIAL

AUTOMOBILE LIABILITY 0 – 5 vehicles

6 or more vehicles

$ 500,000 CSL $1,000,000 CSL

EMPLOYMENT PRACTICES LIABILITY

(Coverage Is Subject To Prior Approval))

$1,000,000 CSL

EMPLOYERS’ LIABILITY

Bodily Injury By Accident

$100,000 Each accident

Bodily Injury By Disease

$500,000 Policy Limit

$100,000 Each Employee

WATERCRAFT

(No Coverage For Jet Skis & Wave Runners)

Less Than 35 Feet in Length More Than 35 Feet but Less Than 50 Feet In Length

Each Accident or Occurrence

$ 500,000

$1,000,000

COMMERCIAL RATES 1 – 9 TOTAL STAFF (Does not include EPLI).

LIABILITY LIMITS

Limits are available up to 10 million ^{1 – 3} ⁴ ⁵ ⁶ ⁷ ⁸ ⁹

1 MILLION $951 1056 1151 1256 1380 1570 1760

2 MILLION $1665 1848 2014 2198 2414 2747 3080

3 MILLION $2378 2640 2878 3140 3448 3924 4400

SUBMIT FOR QUOTATION – Not Staff Rated Eligible

1. Limits greater than 3 million. 2. Annual gross commission income exceeding $8,000,000. 3. Total staff exceeding 9. 4. Owned and/or leased vehicles in excess of 5.

5. Any driver under the age of 25 who is driving a vehicle listed on the agency’s commercial auto policy.

6. Has any watercraft exceeding 26 ft. in length or 60 HP and/or any aircraft exposure (owned or non-owned).

7. Greater than 25% of total premium is written through Brokers, MGA’s, Other Retail Agencies, Insurance Intermediaries, or as a Broker (incl Surplus lines).

8. Greater than 20% of total premium written in the following lines of business (any combination): Flood, Med Mal, all other Professional, Aviation, Bonds, Wet Marine, Life Insurance, Accident & Health.

9. Greater than 15% of total premium written in coastal Property business.

10. Greater than 10% of total premium is placed in the following: Self Insured Captives, Risk Retention Groups, Multiple Employer Trusts, Multiple Employer Welfare Trust. 11. Additional revenue activities generating in excess of $75,00 income

for Loss Control, PEO Marketing, Fee Based Consulting, Mutual Funds Sales.

12. Gross Commission income from real estate operations greater than 10% of total agency commission income or $500,000, whichever is greater.

13. Agency engaged in any business other than insurance. 14. Any underlying claim (incl E&O) in excess of $250,000 within the past 5 years. 15. Any of top 5 companies Agency represents has a Best rating of less

than B+.

17. Excess EPLI limit > $2,000,000.

16. Agency is a cluster or involved in a cluster arrangement

PERSONAL MINIMUM UNDERLYING LIMITS REQUIREMENTS

PERSONAL AUTOMOBILE $500,000/500,000 BI and 100,000 PD OR 500,000 CSL PERSONAL LIABILITY $300,000 Each Occurrence Without Swimming Pools

$500,000 Each Occurrence With Swimming Pools WATERCRAFT

(No Coverage For Jet Skis & Wave Runners) Less Than 35 Feet in Length

More Than 35 Feet but Less Than 50 Feet In Length

$500,000 Each Accident or Occurrence

$1,000,000 Each Accident or Occurrence

PERSONAL UMBRELLA RATES

LIABILITY LIMITS

Limits are available up to 5 million

ANNUAL RATE PER INSURED

1 MILLION $150

ANNUAL RATE PER INSURED includes 2 vehicles written on a Personal Auto Policy, 1 residence and any watercraft under 26 feet in length and less 60 HP.

2 MILLION $250

SUBMIT FOR QUOTATION

1. Limits in excess of 2 million. 4. Any aircraft exposure (owned or non-owned)

2. Any additional residence. 5. Any driver under the age of 25 who drives a vehicle listed on the insured’s personal auto policy. 3. Owned and/or leased vehicles in excess of 2. 6. Any watercraft exceeding 26 ft. in length or with motor(s) exceeding 60 HP .

70 2249 01 06

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Page 1 of 3

Pennsylvania National Mutual Casualty Insurance Company P.O. Box 2361

Harrisburg, PA 17105-2361 800-388-4764 phone 717-257-6960 fax

INSURANCE AGENTS UMBRELLA

SUPPLEMENTAL APPLICATION

GENERAL INFORMATION

1. APPLICANT

^2. ^DATE ^3. ^NEWRENEWAL

5. MAILING ADDRESS

4. EXPIRING POLICY NUMBER

6. PROPOSED POLICY PERIOD (12:01 a.m. Standard Time)

FROM: TO: ^7.TELEPHONE (Incl Area Code)

8. BUSINESS ADDRESS (Enter “Same” or indicate address, if different from above)

^9.FAX NUMBER (Incl Area Code)

10. CONTACT PERSON

11. E-MAIL ADDRESS

12. AGENCY WEBSITE ADDRESS

LIMITS

13. UMBRELLA LIMITS REQUESTED

$1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 ^Other (specify)

$ COMMERCIAL UMBRELLA COVERAGE

INSURED’S RETAINED LIMIT: $10,000 (Standard) $0 (Optional)

$1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 N/A

PERSONAL UMBRELLA ENDORSEMENT (Optional)

INSURED’S RETAINED LIMIT: $250 (Standard) $0 (Optional)

APPLICABLE ONLY IN NEW YORK: IF ANY UNDERLYING INSURANCE INCLUDES DEFENSE WITHIN LIMITS, THIS INSURANCE WILL ALSO PROVIDE DEFENSE WITHIN LIMITS. THE DEFENSE COSTS CHARGED AGAINST THE LIMITS OF INSURANCE WILL NOT EXCEED 50% OF SUCH LIMITS; AND, WE WILL ASSUME ANY DEFENSE COSTS OVER THIS AMOUNT.

ERRORS & OMISSIONS SUPPLEMENTAL INFORMATION

14. RETROACTIVE DATE OF PRIMARY E&O POLICY (if any)

15. EXTENDED DISCOVERY PERIOD? YES NO IF YES, LENGTH OF TIME 16. DEFENSE COSTS AND SUPPLEMENTAL PAYMENTS PROVIDED? ^YES NO IF NO, EXPLAIN IN REMARKS 17. LIST ALL COMPANIES YOU WRITE BUSINESS WITH THAT ARE

NOT RATED B+ OR BETTER BY AM BEST ^DOLLARS PERCENTAGE (%)

18. TOTAL GROSS COMMISSION INCOME OF AGENCY (Do not include Profit Sharing/Contingent Commission)

$

19. HAVE YOU PLACED ANY BUSINESS WITH A COMPANY THAT IS PRESENTLY INSOLVENT? YES NO IF YES, EXPLAIN IN REMARKS SECTION. 20. DOES YOUR AGENCY DERIVE REVENUE THROUGH INTERNET TRANSACTIONS? YES NO

IF YES, WHAT PERCENTAGE?

21. IDENTIFY THE PERCENTAGE OF TOTAL WRITTEN PREMIUM IN THE FOLLOWING LINES OF BUSINESS (if any) FLOOD % MEDICAL MALPRACTICE % COASTAL PROPERTY %

22. IDENTIFY THE PERCENTAGE OF TOTAL WRITTEN PREMIUM PLACED IN THE FOLLOWING (if any)

SELF INSURED CAPTIVES % RISK RETENTION GROUPS % MULTIPLE EMPLOYER TRUSTS % MULTIPLE EMPLOYER WELFARE TRUSTS % 23. DOES YOUR PRIMARY E&O POLICY CONTAIN ANY COVERAGE(S) WITH SUBLIMITS? YES NO

COVERAGE SUBLIMIT (EA CLAIM/AGG) / COVERAGE SUBLIMIT (EA CLAIM/AGG) /

BUSINESS OTHER THAN INSURANCE: (Complete this section only if engaged in any business other than insurance)

24. IS AGENCY LICENSED FOR SELLING REAL ESTATE? YES NO 25. GROSS INCOME

$ ^26.# OF EMPLOYEES

27. OTHER BUSINESS YES NO (If yes, explain in Remarks section) 28. GROSS INCOME

$ ^29.# OF EMPLOYEES

30. ARE OTHER BUSINESS OPERATIONS COVERED BY UNDERLYING POLICIES? (to include E &O) YES NO IF NO, EXPLAIN

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UNDERLYING EXPOSURES (OTHER THAN ERRORS & OMISSIONS)

AUTOMOBILE

31. TOTAL NUMBER OF AUTOS OWNED OR LEASED BY THE AGENCY 32. ANY DRIVERS UNDER THE AGE OF 25? YES NO

33. PROVIDE THE NAMES, DATES OF BIRTH, AND OPERATOR NUMBERS FOR ALL DRIVERS

NAME OF DRIVER DATE OF BIRTH OPERATOR NO.

WATERCRAFT

34. WATERCRAFT:

LIST ALL WTERCRAFT OWNED

WATERCRAFT IS NUMBER APPLICANT ^{USE OF}

WATERCRAFT

YEAR MAKE MODEL DOCKED AT HORSE

POWER ^LENGTH IN-

BOARD BOARD^OUT- OUTBOAR^INBOARD D

OF PAS-

SENGERS ^SLEEPS ^{IS OWNER} ^LEASES RENTS TO ^LOANS/ OTHERS

BUSINESS PLEASURE

% % % % 35. ANY WATERCRAFT ABOVE USED FOR WATER SKIING?

YES NO ^36. ANY WATERCRAFT CHARTERED DURING THIS POLICY PERIOD?

YES NO If yes, explain

AIRCRAFT

37. ANY AIRCRAFT OWNED OR LEASED BY APPLICANT? YES NO 38. ANY AIRCRAFT CHARTERED DURING THIS POLICY PERIOD?

YES NO If yes, explain

39. DOES AGENCY INSURE AIR SHOW? YES NO

LOSS EXPERIENCE

40. CLAIM EXPERIENCE (OTHER THAN E&O)

DESCRIBE ALL CLAIMS DURING THE PAST FIVE YEARS WHICH INVOLVED PAYMENTS/RESERVES IN EXCESS OF $250,000.

DATE OF CLAIM

MO DAY YR AMOUNT RESERVED ^AMOUNT_PAID

$ $

EXCESS EMPLOYMENT PRACTICES LIABILITY

41. INCLUDE EXCESS EMPLOYMENT PRACTICES LIABILITY COVERAGE? ($1,000,000 minimum underlying limit required) YES NO (If yes attach a copy of your primary EPLI application, or ACORD 188 if no underlying EPLI application is available)

42. EXCESS EMPLOYMENT PRACTICES LIABILITY LIMITS REQUESTED (choose one)

$1,000,000 $2,000,000

REMARKS

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Page 3 of 3

PREMIUM CALCULATION for Staff Rated Risks – (See State Rate Page for Rates and Eligibility)

Commercial Liability Limits # of Staff = $

Personal Liability Limits # of Insureds X Ann Rate = $

Total Premium $

Full time staff members shall be rated as one (1), part time staff members shall be rated as one-half (1/2). Note: part time

individuals work 20 hours or less per week. If total number of rating units end in 1/2, round to the next lowest whole

number. Exp.: 5 1/2 = rate policy at 5.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR

OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING ANY 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 THE PERSON

TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not applicable in NE, NY, OH or OR. In DC, TN

and VA insurance benefits may also be denied.)

APPLICABLE IN NEW YORK ONLY:

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.

IMPORTANT

THE STATEMENTS (ANSWERS) GIVEN ABOVE ARE TRUE AND ACCURATE. THE APPLICANT HAS NOT

WILLFULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCE

CONCERNING THIS APPLICATION. THIS APPLICATION DOES NOT CONSTITUTE A BINDER.

________________________________ _

SIGNATURE OF INDIVIDUAL OWNER, PARTNER OR OFFICER DATE SIGNED

IMPORTANT ADDITIONAL INFORMATION:

The following additional information is required to complete this application and must

be attached to this submission:

1) A copy of the primary Errors and Omissions coverage application

2) A copy of each underlying policy Declarations (to include Automobile, General

Liability [or BOP], Employers’ Liability [WC], Errors & Omissions, Employment

Practices Liability, etc.)

3) A copy of Accord 83 (Personal Umbrella Application) for each officer applying for

the personal umbrella endorsement

4) If excess Employment Practices Liability is requested, attach a copy of the primary

EPLI application; or, if a primary EPLI application is not available, attach a copy

of ACORD 188 (Employment Related Practices Liability Section).

Minimum Underlying Limit Requirements are shown on the State Rate Pages.

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SUPPLEMENTAL SCHEDULE OF UNDERLYING INSURANCE

Attach A Copy Of Each Declarations Page.

COVERAGE CARRIER/POLICY

NUMBER POLICY EFF/EXP

DATES ^LIMITS PREMIUM ^ANNUAL

CSL/BI EA. OCC. $

BI EA. PER. $

AUTOMOBILE

LIABILITY

PD EA. ACC $

EACH

OCCURRENCE $

GENERAL AGGR $

PROD & COMP

OPS AGGREGATE $

PERSONAL & ADV

INJURY $

DAMAGE TO

RENTED

PREMISES $

GENERAL

LIABILITY

MEDICAL

EXPENSE $

EACH ACCIDENT $

DISEASE

EACH EMPLOYEE $

EMPLOYERS’

LIABILITY

DISEASE

POLICY LIMIT $

EACH CLAIM $

AGGREGATE

ERRORS &

OMISSIONS

CSL

EACH CLAIM $

AGGREGATE

NOTARY

PUBLIC E & O

CSL

EMPLOYMENT

PRACTICES

LIAB

CSL $

WATERCRAFT EACH ACCIDENT

OR OCCURRENCE $

Supplemental Page 1

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You may fax your application to: (304)