Insurance Agent E & O Application - Clearwater Underwriters

An Excess & Surplus Lines MGA in Clearwater, FL

Insurance Agent E&O Application

About You
Name*
Business Name*
Business Address*
Street Address City State ZIP Code
Phone Number*
Email Address*
Your Business
1. Are your primary services as an insurance agent? (Must be "Yes" to be eligible for this program)*
- Yes
- No
2. 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?*
- Yes
- No
4. 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?*
- Yes
- No
5. 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
*
- Yes
- No
6. 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
*
- Yes
- No
7. 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
*
- Yes
- No
8. 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):*
11. 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?*
- Yes
- No
- Not Required
12. Does your business perform an annual account review with each of your clients?*
- Always
- Never
- Sometimes
13. 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 Coverage
Do you currently have an insurance policy in effect for coverage requested?
- Yes
- No
- Prefer not to answer
Do you have the retroactive date of your current E&O policy?
- Yes
- I don’t know what that is or can’t find it
- I don’t have E&O and currently carry GL only
Please provide your retroactive date.
When would you like coverage to start?
Phone
This field is for validation purposes and should be left unchanged.

Agent Resources

Insurance Agent E&O Application

About You

Your Business

E&O Insurance Coverage

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	Clearwater Underwriters, Inc. 50 S Belcher Rd Ste 101 Clearwater, FL 33765 Phone: (727) 791-6030	Privacy Policy Employment Opportunities © 2018 Copyright All Rights Reserved