Professional Liability Insurance - Application For Insurance Agents & Brokers / Insurance Consultants

Submission of completed application incurs no obligation for purchase of Insurance. It merely servers to furnish the company with underwriting data for the designing of proposal and rate.


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NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

1. Applicant (Full Legal Name of Brokerage to be Shown As Named Insured)

2. Mailing Address

Phone Number

Fax Number

E-Mail Address

3. Branch Offices

4. Business Type Corporation Partnership Individual

Number of years under present ownership (If less than three years, attach detailed supplement of Applicant's insurance experience to paper form.)

5. Is the Applicant Firm controlled, owned or associated with any other firm, corporation or company? Yes No

If "Yes", please supply full details.

6. During the past ten years has the name of the Applicant Firm been changed or has any other business been purchased or any merger or consolidation taken place? Yes No

If "Yes", please supply full details.

7. The Applicant is licensed as (check all that apply): Insurance Agent Insurance Broker Life Insurance Agent General Agent Carries on the practice of Insurance Consultant Carries on the practice of Reinsurance Broker

Please provide, full details of those professional services rendered as an Insurance Consultant, or Reinsurance Broker if coverage required:

8. List province(s) where licensed:

9. Is the Applicant a member of a Professional Association(s)? Yes No

If "Yes", please give full details.

10. List all insurance companies with whom you have an agency contract.

11. List all other insurance companies, specialty markets and brokers with whom you place business.

12. List all insurance companies with whom agency contacts hvave been terminated in the last five years.

13. Approximate annual gross premium volume written (excluding life) $

14. Approximate annual life insurance commission $

Life Insurance Co. represented

15. Indicate total gross annual commission from investment products: Mutual Funds

RRSP/GIC's

Financial Planning

16. Do you place business on a brokerage basis? Yes No

If "Yes", what type of insurance?

Approximate annual premium volume

17. Do you accept brokerage business? Yes No

If "Yes", what types of insurance?

Approximate annual premium volume

17 A. OFFICE PROCEDURES a) Is incoming mail date stamped? Yes No

b) Are verbal binders confirmed in writing? Yes No

c) Are copies of binders mailed to both insured and company promptly? Yes No

d) Is there a procedure for documenting all telephone conversations? Yes No

e) Is a policy expiration list maintained? Yes No

f) Are all policies and endorsements checked for accuracy before mailing? Yes No

g) Are files marked to make sure mortgagees and lien holders are notified of cancellation of material changes? Yes No

h) Does applicant have in-house training sessions and/or encourage employees to take outside training courses such as IIC or CAIB? Yes No

i) Does applicant have a specific orientation program for new employees? Yes No

j) Does firm use a computer or data processing in its operation? Yes No

If "Yes", what system?

k) Is there a back-up procedure for when applicant is away from the office? Yes No

Please explain

l) Describe the firm's diary abeyance system

17 B. Are staff members familiar with the "Claims Made" Comprehensive General Liability wording? Yes No

If "No", what plans are made to have staff trained in the "Claims Made" wording?

18. Give the approximate percentages of total business written (equaling 100%): Automobile-Standard (%)

Automobile-Sub Standard** (%)

Property-Standard (%)

Property-Sub Standard** (%)

Casualty (%)

Professional Liability (%)

Surety (%)

Ocean Marine (%)

Give the approximate percentages of total business written (equaling 100%): Personal lines, including Auto (%)

Commercial lines (%)

Give the approximate percentages of total business written (equaling 100%): Agency Billing (%)

Company or Direct Billing (%)

**Placed with specialty markets. Autoplan Commission Income $

19. The aforementioned lines include: (Give annual premium volume in each class.) Livestock Mortality $

Helicopter and Fixed Wing Aircraft $

Consulting & Risk Managment (for Fee) $

Third Party Administration (for Fee) $

Medical / Physicians / Hospitals Professional $

Biotech Pharmaceutical $

Interurban Transport $

Managing General Agency $

20. Does the Applicant engage in: Reinsurance Business? Yes No

Foreign Business? Yes No

If "Yes" to either, please provide full details.

21. Employees Number of Owners, Officers or Partners

Number of Staff

Number of Licensed Agents (including Owners, Officers, or Partners)

Total Number of Staff (includes all the above)

Non-Employees Number of Commission Salespersons, handling the Applicant's business, who are licensed under Brokerage license

Number of Sub-Brokers, (who are placing their own business through the Applicant's facilities)

If commission Salesperson and/or Sub-Brokers are to be included as Additional Named Insureds, please supply the following information: Commission Salespeople - Identify each by name and furnish amount of annual gross premium volume solicited.

Sub-Brokers - Identify each by name and furnish answers (on the basis of previous questions) regarding the business placed through your agency.

22. Does the Applicant service business writing for any agencies or brokers not previously referred to herein? Yes No

If "Yes", provided detailed narrative statement

23. Has the applicant and its staff taken an Errors & Omissions Loss Prevention Seminar in regard to mandatory continuing education? Yes No

If "No", please confirm when seminar will be taken.

24. Has the Applicant or any Owner, Officer or Partner been the subject of any insurance authority's disciplinary action? Yes No

If "Yes", provide detailed narrative statement

25. Has any application for Insurance Agent & Brokers Professional Liability Insurance on behalf of the Applicant or of its present Partners, Executive Officers, or Directors, or, to the knowledge of the Applicant, on behalf of its predecessors in business, ever been declined, cancelled or renewal refused? Yes No

If "Yes", provide detailed narrative statement

26. Have any Professional Liability claims been made against the Applicant, any of the present Partners, Executive Officers, Directors, Commission Salespersons or Sub-Brokers; or, to the knowledge of the applicant, against its predecessors in business or any Partner, Executive Officer or Director? Yes No

If "Yes", provide detailed narrative statement

27. Does the Applicant, its Commission Salespersons or its Sub-Brokers know of any circumstances, which could result in any Professional Liability claim being made against the Applicant, its predecessors in business or any past or present, Partners, Executive Officers, Directors, Commission Salesperson or Sub-Brokers? Yes No

If "Yes", provide detailed narrative statement

28. Is the Applicant engaged in any other business or profession? Yes No

If "Yes", provide detailed narrative statement including reference to operation, if any, as a Real Estate Broker or Salesperson, Property Appraiser, Title Searcher, Realty Property Management firm, Mortgage Broker, etc.

29. Please detail Insurance Agents & Brokers' & Insurance Consultants' Professional Liability Insurance held by the Applicant Firm during the PAST FIVE YEARS: Policy 1 (Current Policy): Insurance Company

Policy Number

Limit of Liability

Deductible

Policy Period

Premium

Policy 2 (Next Most Recent Policy, if within past 5 years): Insurance Company

Policy Number

Limit of Liability

Deductible

Policy Period

Premium

Policy 3 (Next Most Recent Policy, if within past 5 years): Insurance Company

Policy Number

Limit of Liability

Deductible

Policy Period

Premium

Policy 4 (Next Most Recent Policy, if within past 5 years): Insurance Company

Policy Number

Limit of Liability

Deductible

Policy Period

Premium

Policy 5 (Next Most Recent Policy, if within past 5 years): Insurance Company

Policy Number

Limit of Liability

Deductible

Policy Period

Premium

Date UNINTERRUPTED insurance first began:

30. Coverage Requested Item 1: Limit(s) of Liability

Aggregate Limit(s)

Deductible(s)

Item 2: Limit(s) of Liability

Aggregate Limit(s)

Deductible(s)

Item 3: Limit(s) of Liability

Aggregate Limit(s)

Deductible(s)

REMARKS (optional - or use to complete questions above)