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| E & O Professional Liability |
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Contact Information |
| Your Name: |
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| Corporate Name: |
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| dba (if applicable): |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Fax: |
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| E-Mail: |
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| Number of Locations: |
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| Number of Licensed Staff: |
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Total Employees:
(incl.licensed staff) |
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Agency Information |
| Year agency established: |
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| If less than three (3) years ago, please attach resumes of all principals. |
| Owners' years of experience: |
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Coverage Information |
| Limits of Liability desired: |
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| Deductible desired: |
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Production Information |
| a: Indicate the percentage of business you placed in each category acting as a... |
| Retail Agent/Broker: |
% |
| or, are you acting as an... |
| MGA: |
% |
| Wholesaler: |
% |
| Surplus Lines Broker: |
% |
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Total of all categories must equal 100% |
| b: Please indicate the dollar amount of your premium volume derived from each Personal & Commercial line of business listed below and commission income for each Life, Accident and Health line of business: |
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| Personal Lines: |
Premium Volume |
| Standard Auto: |
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| Non-Standard Auto/Motorcycles/RVs: |
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| Homeowners/Mobile Homes/Umbrella: |
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| Personal Marine: |
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| Total Personal Lines: |
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| Commercial Lines: |
Premium Volume |
| Auto (other than long-haul trucking): |
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| Long-Haul Trucking: |
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| Business Owners' Policy: |
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| General Liability & Property: |
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| Workers Comp (non-retro rated): |
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| Workers Comp (retro rated): |
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| Bonds: |
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| Umbrella/Excess: |
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| Aviation: |
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| Wet Marine: |
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| Professional Liability/Medical Malpractice: |
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| Total Commercial Lines: |
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| Life, Accident & Health: |
Commission |
| Individual Life: |
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| Individual Accident & Health: |
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| Group Life: |
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| Group Accident & Health: |
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| Securities (supplement required): |
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| Total Life, Accident & Health Lines: |
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c: Please indicate the premium volume produced by or through you
and the revenues/fees earned by you. |
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Last Year |
Current Year (est.) |
| Premium Volume: |
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| Revenue/Commission: |
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| Non Revenue/Comm (whsler only): |
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| Accident/Health Comm: |
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| Fee Income: |
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d: Income derived from Non-Insurance activities. |
| Income Amount: |
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| Source of Income: |
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Insurance Company Appointments |
Please list the top three (3) insurers (including companies, syndicates, captives, etc.)
that you place business with. |
Insurer
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Premium Volume
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A.M. Best Rating |
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Percentage of total premium volume placed with non-rated
(B or lower) by A.M. Best |
% |
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Existing E&O Coverage |
| Do you currently have errors and omissions insurance in force? Yes
No
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| Insurer: |
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| Limits: |
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| Deductible: |
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| Premium: |
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| Expiration Date of Current Policy: |
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| Retroactive Date of Current Policy: |
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Disciplinary Action or Claims |
| Have you been the subject of disciplinary action or investigation as a result of professional activities? |
Yes
No
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| Have there been any errors and omissions claims made during the past five (5) years? |
Yes
No
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| Do you have any knowledge of any potential errors or omissions claim(s)? |
Yes
No
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| Are you being non-renewed, or have you been non-renewed in the past five (5) years? |
Yes
No
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| If "Yes" to any of the above, please provide an explanation below: |
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| Note to Underwriter: |
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| Name of Person Completing Application: |
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| Date of Application: |
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