Insurance Agent E&O Application About YouName*Business Name*Business Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Your Business1. Are your primary services as an insurance agent? (Must be "Yes" to be eligible for this program)*YesNo2. For the next 12 months, what is your business's estimated total annual revenue from commission and other sources? (Must be under $1,000,000 to be eligible for this program)*STATEMENTS 3 THROUGH 7 MUST BE "NO" TO BE ELIGIBLE FOR THIS PROGRAM 3. Based on your knowledge and knowledge of your businesses current and past partners, officers, directors and employees, during the last five years has a third party made a claim against your business or do you know of any reason why someone may make a claim?*YesNo4. Has your businesses current and past partners, officers, directors, board members, trustees or employees ever been subject to disciplinary action by authorities as a result of professional activities?*YesNo5. Does your business provide any of the following: -Actuarial advice -Financing of financial auditing -Investment or tax advice -Legal advice -Lobbying and/or political advice -Medical advice -Mergers and acquisitions or business valuations *YesNo6. Does your business provide services in the capacity of the following: -Managing General Agent (MGA) -Managing General Underwriter (MGU) -Professional Employer Organization (PEO) -Program Administrator or Third Party Administrator (TPA) -Reinsurance intermediary -Risk Retention Group (RRG) -Wholesale broker -Health Maintenance Organization (HMO) plan creator, manager and/or administrator *YesNo7. Does your business provide insurance placement or advice for any of the following insurance products or services: -Aviation insurance -Lawyer’s liability insurance -Mining insurance -Multiple Employer Welfare Arrangements (MEWA) -Variable annuities, mutual funds, stocks or investment bonds -Variable life insurance*YesNo8. Other than the business address provided above, how many additional locations does your business own or rent?9. Approximately when did your business begin?*10. What best describes your business’s ownership structure (select one):*Individual / Sole ProprietorJoint VentureLimited Liability CorporationPartnershipTrustCorporation or other Organization11. If required by state law, do you or the principal of your firm maintain current and valid professional training, certifications, licenses or designations for all services you provide?*YesNoNot Required12. Does your business perform an annual account review with each of your clients?*AlwaysNeverSometimes13. What type of insurance placement services does your business provide? (Check all that apply) Personal Lines Commercial Lines Life, Accident or Health E&O Insurance CoverageDo you currently have an insurance policy in effect for coverage requested?YesNoPrefer not to answerDo you have the retroactive date of your current E&O policy?YesI don’t know what that is or can’t find itI don’t have E&O and currently carry GL onlyPlease provide your retroactive date.When would you like coverage to start?CommentsThis field is for validation purposes and should be left unchanged.
