SPECIMEN
IA 95 00 02 04 Page 1 of 8
APPLICATION FOR INSURANCE AGENTS AND BROKERS
ERRORS & OMISSIONS LIABILITY INSURANCE
NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO
“CLAIMS” FIRST MADE DURING THE POLICY PERIOD. THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES
OR SETTLEMENTS WILL BE REDUCED BY “DEFENSE EXPENSES,” AND “DEFENSE EXPENSES” WILL BE
APPLIED AGAINST THE RETENTION. THE INSURER WILL HAVE NO DUTY UNDER THE POLICY TO DEFEND
ANY “CLAIM.” THE ENTIRE APPLICATION SHOULD BE CAREFULLY READ BEFORE IT IS EXECUTED.
APPLICANT'S INSTRUCTIONS:
1. Answer all questions. If the answer requires detail, please attach a separate sheet.
2. Application must be signed and dated by owner, partner or officer.
3. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
(PLEASE TYPE OR PRINT IN INK)
1. Application Information
a) Name of Applicant:________________________________________________________________________________
b) Principal Address:_________________________________________________________________________________
City:__________________________________________________ State:_________ Zip Code:___________________
c) Phone: ___________ Fax Number: ____________________ Email: ______________
d) [ ] Corporation [ ] Partnership [ ] Individual [ ] Other (Please Specify) ________________
e) Number of Employees: Full Time ________ Part Time ________ Total ________________
f) Year business established _____ Please provide resume of principal(s) if less than 10 years old.) g) Member of agents/brokers associations: [ ] PIA [ ] NAPSLO [ ] AAMGA [ ] IIAA
h) (i) Number of branches: ___________
(ii) Please attach list of each branch location:
2. Applicant Operations
a) (i) Does the Applicant or any of its principals own, control or act as director or officer of any other insurer, reinsurer or other insurance-related entity? [ ] Yes [ ] No
If yes, please identify entity and relationship. _________________________________________
(ii) During the past 5 years, has the Applicant’s name been changed, or has any other business purchased, merged or consolidated with the Applicant? [ ] Yes [ ] No
If yes, give dates, names, premium volumes and details. _______________________________
(iii) Name of each shareholder/owner and percentage owned: _______________________________
(iv) Is the Applicant owned or controlled by or under common ownership or associated with any other business or entity? [ ] Y e s [ ] No
If yes, provide name, percentage or ownership and description of business of parent or controlling interest.
_______________________________________________________________________________
b) Names of owned or controlled subsidiary operations and percentage owned: (Indicated at the left with an “X” those entities 100% owned to be shown as additional Insureds, and provide narrative description of operations on a separate sheet.)
__________% _________________________________________________________________________
SPECIMEN
IA 95 00 02 04 Page 2 of 8
_________% __________________________________________________________________________
_________% __________________________________________________________________________
c) Please List:
(i) Types of commercial accounts written (e.g., restaurants, manufacturing, light industrial, municipalities, etc.):
______________________________________________________________________________________
(ii) Classes of business in which the Applicant specializes: ____________________________________
d) Does the Applicant place any business in or have any involvement with any self-insured captive or Risk Retention Act Program, Multiple Employer Trust or Multiple Employer Welfare Arrangement? [ ] Yes [ ]No If yes, please describe, including premium volume and fees: ___________________________________
e) List the complete names of the insurance companies in which the Applicant places business and which account for at least 85% of your total premium volume. (Attach separate sheet if necessary.)
____________________________________________________________________________________
____________________________________________________________________________________
f) Staff
(i) Give number of the Applicant’s total staff (including part-time):
__________Active partners, directors, officers, owners __________Employed solicitors, brokers
__________Other employees __________Total
(ii) Provide list of names of partners or officers on a separate sheet.
h) Reinsurance placed: Volume $ ___________
Facultative ___________%
Treaty ___________%
Total 100%
i) Do you operate outside of the U.S.A? [ ] Yes [ ] No
If yes, attach a description of operations, locations and annual premium volume.
3 . APPLICANT REVENUE
a) What percentage of total income comes from:
(i) Insurance ______% Annuities:
Premium Financing _____% Fixed _______%
Real Estate ______% Variable _____%
Mutual Funds ______%
Other – specify Total 100%
(ii) Give dollar volume of mutual funds sales in last 12 months:
Fees generated in the last 12 months from operations listed below:
SPECIMEN
IA 95 00 02 04 Page 3 of 8
Claims Adjusting $ __________
Counseling (Insurance Programs) $ __________
Real Estate Appraisal $___________
Engineering $___________
*Third Party Administrator $___________
Administrator for Insured Plans $___________
Other $___________
*If operations, include third party administration, supplemental application must be completed.
(iii) Other than those listed above, is the Applicant or any of its principals engaged in any other business?
[ ] Yes [ ] No.
Please describe:
(iv) Approximate percentage of the total annual volume Applicant does as:
1. Agent _____%
Broker _____%
Managing General _____%
Surplus Lines Broker _____%
Other (specify) Must Total 100__%
2. Retailer or Business direct from Insureds _____%
Wholesale or Business accepted from other agents _____%
Must Total 100__%
b) Total annual premium volume for:
Surplus Lines: ________%
Assigned Risk, Governmental Pool and Fair Plan: ________%
c) Total annual premium volume:
(i) Life and Accident/Health:
1. Group Life, Accident/Health: $___________ Volume _______%
2. Individual Life, Accident/Health: $___________ Volume _______%
Total: $___________ Volume _______%
(ii) Personal Lines:
Automobile: $___________ Volume _______%
Homeowners: $___________ Volume _______%
Other Personal Lines written by line:
_______________________ $___________ Volume _______%
_______________________ $___________ Volume _______%
Total: $___________ Volume _______%
SPECIMEN
IA 95 00 02 04 Page 4 of 8
(iii) Commercial Lines:
General Liability: $___________ Volume _______%
Workers' Compensation: $___________ Volume _______%
Commercial Auto: $___________ Volume _______%
Commercial MultiPeril: $___________ Volume _______%
Other Commercial Property: $___________ Volume _______%
Inland Marine: $___________ Volume _______%
Wet Marine*: $___________ Volume _______%
Bonds - Surety: $___________ Volume _______%
Bonds - All Other: $___________ Volume _______%
Aviation*: $___________ Volume _______%
Umbrella/Excess: $___________ Volume _______%
Physicians & Hospital Professional Liability: $___________ Volume _______%
Other Professional Liability/D&O: $___________ Volume _______%
Other (specify): $___________ Volume _______%
$___________ Volume _______%
Total: $___________ Volume _______%
* If 20% or more of agency's volume is wet marine or aviation, supplemental application must be completed.
d) (i) Premium Volume:
Year
Two Years Prior
___________ $ _______
One year Prior ___________ $ _______
Current Year ___________ $ _______
Next Year ___________ $ _______
(ii) Commission:
Actual last fiscal year: $_________ through ____/____/__
Estimated next fiscal year: $____________ through / / (iii) Premium written under your surplus lines license:$ _________
(iv) Number of policies
Next 12 months Current 12 months
_________ _________
e) List all insurance companies and volume of business Applicant placed with companies having an A.M. Best Rating of B or below, or with companies not currently rated:
f) What volume of total annual premium for the agency is currently placed with:
(i) Lloyd's of London: $_________
SPECIMEN
IA 95 00 02 04 Page 5 of 8
(ii) Other foreign insurers: $_________
(iii) Please list foreign insurers and brokers below:
_________ _________ _________
_________ _________ _________
g) Office Procedures
(i) Does the agency utilize a computerized production and accounting system? Yes__ No __
(ii) Is the agency on-line with any carrier? Yes__ No __
Name of Carrier_______________
(iii) Is the agency using the Internet? Yes__ No __
Does the agency have Home Page and/or Web Site? Yes__ No __
State I.D.___________
If yes, is it used for marketing? Yes__ No __
If yes, is it used for sales/ Yes__ No __
If Yes, are applications completed/submitted through the Internet? Yes__ No __
(iv) Is incoming mailed date stamped?
Yes__ No __
(v) Are copies of binders mailed to the insured and/or the company within specified guidelines? Yes__ No __
(vi) Is there a procedure for documenting telephone conversations? Yes__ No __
(vii) Is a policy expiration list maintained? Yes__ No __
(viii) Are all applications, policies and endorsements checked for accuracy? Yes__ No __
(ix) Are all files marked to ensure certificate holders, regulatory agencies, etc. are notified of cancellation or material
changes? Yes__ No __
(x) Is there a back-up procedure for when agency personnel are away from the office? Yes__ No __
(xi) Does the agency have a diary/suspense system? Yes__ No __
(xii) Does the applicant have an Office Manual? Yes__ No __
(xiii) Does the applicant have a specific orientation program for new employees? Yes__ No __
4 . For Managing general Agents and Administrators of Insured Programs
a) List all companies for whom Applicant is Managing General Agency or Program Administrator or have binding authority. (Attach separate sheet if necessary.)
Company Lines of Insurance No. of Years Premium Volume Loss Ratio Last 3 yrs.
____________ _______________ ________ ______________ ____% ____% ____%
____________ _______________ ________ ______________ ____% ____% ____%
b) Producers:
(i) Number from whom Applicant receives business: ______________
(ii) Number that Applicant has appointed as agents with binding authority: ___________
Premium Volume: $ ___________
(iii) Lines of business for which they are granted authority: _____________
SPECIMEN
IA 95 00 02 04 Page 6 of 8
(iv) What supervision does Applicant exercise over them? ________________
c) List all other companies for which the Applicant has been Managing General Agent or Program Administrator or agent with binding authority in the past five years. __________________
d) List all functions the Applicant performs as Managing General Agent or Program Administrator or agent with binding authority, including rating, quoting, claims handling, policy issuance, etc.
_______________________________________________________________________
e) Specify the maximum limit and claim handling authority for each carrier with which the Applicant has binding authority:
Limits Carriers Claim Handling Authority Marine/Inland $___________ _________________ __________________________
Marine/Wet $___________ _________________ __________________________
Property $___________ _________________ __________________________
Casualty $___________ _________________ __________________________
Aviation $___________ _________________ __________________________
Life/Accident $___________ _________________ __________________________
Medical $___________ _________________ __________________________
5. APPLICANT HISTORY
a) List prior Insurance Agents & Brokers E&O Coverage for the past 3 years. If none, state none.
Policy Limits of Liability Deductible Expiring Premium Expiration __________ _____________ __________ ______________ __________
__________ _____________ __________ ______________ __________
__________ _____________ __________ ______________ __________
b) Has any application for similar insurance on behalf of Applicant, or any of its partners, executive officers or directors, or to Applicant’s knowledge, on behalf of the predecessors in business, ever been declined, canceled or renewal refused?
[ ]Yes [ ] No
If yes, please explain: ______________________________________________________________________________
c) Have any claims been made during the past five years against the Applicant , or any of its past or present partners, officers, directors, solicitors, office brokers, or employees, any predecessors in business or against any corporation that any proposed Insured was formerly employed by, associated with or had an interest in?
[ ]Yes [ ] No
If yes, please attach a statement giving details and status of each claim including dales, basis of claim, amount of claim, deductibles, payments, open reserves.
d) Is the Applicant, or any of its partners, officers, directors, solicitors, office brokers or employees, aware of any circumstances or any allegations or contentions of any incident which may result in a claim against the Applicant, its predecessors in business or any past or present partner, officer, director, solicitor, office broker or employee?
[ ] Yes [ ] No
If yes, please attach a statement giving details.
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSONS AND ENTITY(S) PROPOSED FOR THIS INSURANCE DECLARES THAT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO COMPLETE THE INSURANCE.
THE UNDERSIGNED DECLARES THAT THE PERSON(S) AND ENTITY(S) PROPOSED FOR THIS INSURANCE UNDERSTAND:
SPECIMEN
IA 95 00 02 04 Page 7 of 8
(A) THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED, AND MAY BE COMPLETELY EXHAUSTED BY THE PAYMENT OF “DEFENSE EXPENSES,” AND IN SUCH EVENT, THE INSURER WILL NOT BE RESPONSIBLE FOR ANY ONGOING DEFENSE EXPENSES OR FOR THE AMOUNT OF ANY JUDGEMENT OR SETTLEMENT TO THE EXTENT THAT ANY OF THE FOREGOING EXCEED ANY APPLICABLE LIMIT OF LIABILITY;
(B) “DEFENSE EXPENSES” WILL BE APPLIED AGAINST THE RETENTION;
(C) THIS POLICY APPLIES ONLY TO “CLAIMS” FIRST MADE OR DEEMED MADE DURING THE “POLICY PERIOD,” OR, IF PURCHASED, ANY EXTENDED REPORTING PERIOD;
(D) THE INSURER HAS NO DUTY UNDER THIS POLICY TO DEFEND ANY “CLAIM.”
IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE POLICY EFFECTIVE DATE, THE APPLICANT WILL NOTIFY THE INSURER WHO MAY MODIFY OR WITHDRAW ANY QUOTATION.
THE INFORMATION CONTAINED AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE INSURER AND, ALONG WITH THE APPLICATION, IS CONSIDERED TO BE PHYSICALLY ATTACHED TO THE POLICY AND WILL BECOME PART OF THE POLICY IF ISSUED.
Notice to Arizona Applicants: For your protection, Arizona law requires the following statement to appear on
this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to
criminal and civil penalties.
Notice to Arkansas Applicants: 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.
Notice to Colorado Applicants: 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 and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to
a policy holder 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 of Regulatory Agencies.
Notice to District of Columbia Applicants: 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.
Notice to Florida Applicants: Any person who knowingly and with 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 in the third degree.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company
or other person files a statement of claim containing materially false information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Notice to Louisiana Applicants: 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.
Notice to Maine Applicants: 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 or a
denial of insurance benefits.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
Notice to New Mexico Applicants: 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 civil fines and criminal penalties.
SPECIMEN
IA 95 00 02 04 Page 8 of 8
Notice to New York Applicants: 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 is subject to a civil penalty not to exceed $5,000.00
and the stated value of the claim for each such violation.
Notice to Ohio Applicants: Any person who, with 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.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete
or misleading information is guilty of a felony.
Notice to Pennsylvania Applicants: 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.
Notice to Tennessee Applicants: 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.
Notice to Virginia Applicants: 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.
____________________________________________________________________________________________________________
APPLICANT:
__________________________________________________ _________________________________________ _______________
__________________________________________________ _________________________________________ _______________
BY (Signature of Chairman and/or President) TITLE DATE
It is agreed and understood that the Application will only be executed by the Chairman and/or President of the Applicant acting in their capacity(s) as the authorized agent of the individual(s) and entity(s) proposed for this insurance.
________________________________________________________ ___________________________________________________
PRODUCER (Insurance Agent or Broker): INSURANCE AGENCY OR BROKERAGE:
________________________________________________________ __________________________________________________
INSURANCE AGENCY OR BROKERAGE TAXPAYER ID AGENT OR BROKER LICENSE NO.:
OR SOCIAL SECURITY NO.:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ADDRESS OF AGENT OR BROKER (include Street, City, and Zip Code):
____________________________________________________________________________________________________________
E-MAIL ADDRESS OF AGENT OR BROKER:
____________________________________________________________________________________________________________
SUBMITTED BY (Insurance Agency or Brokerage):
________________________________________________________ ___________________________________________________
INSURANCE AGENCY OR BROKERAGE TAXPAYER ID AGENT OR BROKER LICENSE NO.:
OR SOCIAL SECURITY NO.:
____________________________________________________________________________________________________________
ADDRESS OF AGENT OR BROKER (include Street, City, and Zip Code):
