Insurance Agents & Brokers Professional Liability Form Page 2
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220. Indicate the percentages of premium volume derived from each line of business listed below must total 100%
PERSONAL LINES
%
COMMERCIAL LINES
%
Auto (Standard)/Motorcycles
Auto (Other than Long Haul Trucking)
Auto (Non-standard)/Motorcycles
Long Haul Trucking
Homeowners/Dwelling
Business Owners’ Policy
Umbrella
General Liability & Property (Non-BOP)
Other (Describe):
Workers’ Comp
Risk Retention Group
%
Bonds
LIFE, ACCIDENT & HEALTH
Individual Life
Crop/Animal Mortality
Individual Accident & Health
Aviation
Group Life
Ocean Marine
Group Health
Prof. Liability
Fixed Annuities
Medical Malpractice
Other (Describe):
Directors & Officers
%
Total (100%):
0
Office Procedures (loss control credits are given in this area)
a.
Are copies of binders mailed to insured and/or the company promptly?
Yes
No
b.
Is there a procedure for documenting phone conversations?
Yes
No
c.
Is a policy expiration list maintained?
Yes
No
d.
Are all policies and endorsements checked for accuracy?
Yes
No
e.
Does agency have a follow-up /suspense system?
Yes
No
f.
Does the Applicant have an Office Procedures Manual?
Yes
No
g.
Does Applicant document a client’s refusal to accept coverage/limits limitations?
Yes
No
h.
Does agency utilize a computerized production and accounting system?
Yes
No
i.
Is incoming mail date stamped?
Yes
No
j.
Does the Applicant delegate binding authority to sub-producers?
Yes
No
k.
Are requests required to be in writing when a customer desires their insurance
Yes
No
l.
Reduced or Eliminated?
Yes
No
m.
Does the Applicant conduct any business other than Property & Casualty Insurance?
Yes
No
If yes, please explain (i.e. DMV Registration):
% From outside producers?
What percentage of the Applicant’s business is: Received direct?
%
Prior carrier information:
Premium:
Premium:
I/WE HEREBY DECLARE THAT THE ATTACHED STATEMENTS AND PARTICULARS ARE IN ALL RESPECTS TRUE AND ARE MATERIAL TO
THE ISSUANCE OF INSURANCE HEREIN AND THAT I/WE HAVE NOT OMITTED, SUPPRESSED OR MIS-STATED ANY FACTS AND I/WE AGREE
THAT THIS PROPOSAL FORM SHALL BE THE BASIS OF THE CONTRACT AND SHALL WE BE DEEMED A PART OF THE POLICY AS IF
ANNEXED THERETO. SIGNATURE OF THIS FORM DOES NOT BIND THE FIRM OR THE UNDERWRITERS TO COMPLETE THE INSURANCE.
How did you hear about us?
Web-site
Insurance Journal
Email Blast
Other: _______________________
Applicant Signature:
_____________________________________________
Date: _____/
__/___
05/23/2016
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