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705 West Avenue B #320 Garland, TX 75040
972 840 0832 tel 972 840 0189 fax
866 840 8004 toll free
www.insurancebydesign.info
Johnny@InsuranceByDesign.info
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APPLICANT ACKNOWLEDGEMENT
The undersigned understands, other than Notary, all other BOND type coverage is excluded.
The undersigned understands, acknowledges and accepts that if coverage is provided it is ONLY for Insurance agent type activities.
The undersigned agrees to read the EXCLUSIONS section of policy if issued.
The undersigned understands, acknowledges and accepts that they release and forever HOLD HARMLESS the insurer from any claims that would arise from/or as would relate to my binding risks WITHOUT WRITTEN permission from my providers.
The undersigned understands and accepts that any policy issued will provide coverage on a CLAIMS MADE basis and that the limit of liability to pay damages shall be reduced and may be completely exhausted by payment of claims expense.
The undersigned represents that the statements set forth herein are true, complete and accurate and that there has been no attempt at suppression or misstatements of any material facts known, or should be known, and agrees that this application shall become the basis of any coverage provided and a part of any policy that may be issued.
The undersigned authorizes the insurer to obtain a copy of the credit history of all the applicants for the underwriting of insurance for which applied.
The undersigned understands that misrepresentation, false, incomplete, misleading answers, omissions, or failure to disclose any PRE-EXISTING situation which could lead to the presentation of a claim will RELEASE the insurer from any claim payment or defense expense.
BY MY SIGNING I HAVE ACKNOWLEDGED MY READING, MY UNDERSTANDING, AND MY ACCEPTANCE OF THE ABOVE STATEMENTS.
X_________________________
Printed Name Title Signature Date
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- Applicant's name as appears on license
- Business name (dba)
Is business name on record with County Assumed names Department ? Y N
- Street Address
City State Zip
- Any branch offices? Y N If yes attach listing each office with phone and fax.
- Phone fax email
- Application is Individual Partnership Corporation Other
- How would you describe your credit ? Great Good Average Poor Bad
- Date Agency was established (as applicant's current business name)
- List all owners/officers and their percent of ownership interest. Attach copy of all licenses.
- Is applicant engaged in any other business other than Insurance? Y N
Explain
- Is applicant controlled, owned, affiliated or associated with any other firm, agency, Corporation or Insurance Company ? Y N
If Yes, How?
- During the past 3 years has the name of the Agency been changed or has any other business or Agency been acquired, merged into or consolidated with the applicant?
Y N If Yes, explain?
- E & O policy currently in force ? Y N (Copy of expiring policy must be attached showing retroactive date)
Expiration Date Retroactive Date
- List last three E & O providers.......... If none state NONE !!!!!
- Has the applicant ever had an E & O policy declined, renewal refused, or canceled? ( this also includes nonpayment of monthly payment)
Y N If yes explain - What percentage of volume is standard ? % Nonstandard? %
- What percent of volume is admitted ? % Non admitted? %
- State commission income by area of written premium. (combined total should be 100% )
P&C personal lines % P&C commercial lines % Life and Health %
- What was the total NET (new and canceled) volume all lines all companies ?
Last Year $ This Year $ Next Year $
- What was the total commission income all lines all Companies?
Last year $ This Year $ Next Year $
- List volume last 12 months by Ins. Co. or General Agent starting with largest first.
Combined total volume for this listing should be the same as last year's volume shown in question 19.
- What is the percent of applicant's annual commission income by line of coverage ?
- What percent of your volume is received direct from your insureds ? %
- Is all incoming mail date stamped and worked every business day ? Y N
- How long do you maintain your records ?
- Do you give written binders to your insureds ? Y N
- How and when do you notify the insurer of your binding (if allowed) them to a risk?
Explain
- Do you record and document for the file all business related conversations ? Y N
- Do
you require a form of written request from your insureds who desire
their coverage to be increased, reduced or eliminated
? Y N
- Do you advise insureds of all lines of coverage ? Y N
If no, why not?
- Are investigations made under provision of the Fair Credit Reporting Act ? Y N
- If accepted by the Insurer, what is the requested effective date?
- Requested limit $/$ Requested deductible $
NOTE !!!! NOTE !!!! An answer of YES to the next questions will require
a written answer in complete detail on the Applicant's letterhead and
must be attached to the application.
- Has
the applicant or any employee of the applicant ever been subject to
disciplinary action by any State Agency or Insurance Department
? Y N
- Have any claims or suits been made against applicant or any staff member? Y N
- After
inquiry of each person proposed for insurance, is the applicant AWARE
of ANY circumstance, omission, error or offense which may result in a
claim being made against the applicant or any of applicant's employees
? Y N
By my signing, I am stating all answers in this application are true and complete statements.
X___________________________
Printed Name Title Signature Date
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