Renewal Application
This is a renewal application for a claims made policy
Renewal of

  1. Applicant's name as appears on license  
  2. Business name (dba)  
  3. Street Address
  4. City  State  Zip 
  5. Phone  Fax  Email 
  6. Any branch offices?  Y N If yes attach listing each office with phone and fax .
  7. Any change in Owners Officers, Directors, Partners  Y N
  8. What was total NET (new, endorsed, cancelled) VOLUME all lines all Cos ?
    Last 12 months $ Next 12 months $
    COMMISSION Last 12 months $ Next 12 months $
  9. What is the percent of applicant's annual commission income by line of coverage ?
    Total for all 3 sections must equal 100%
    10. Personal Commercial Life, A&H
    % Automobile % Automobile % Life
    % Homeowners % Fire % Health
    % Cycle % Package % Accident
    % Boat % Workers Comp % Other
    % Other % Other
  10. List volume of last 12 months by Ins. Co. or General Agent starting with largest first.
    Insurance Company or General Agent Volume Admitted Rating
    #1 Y  N
    #2 Y  N
    #3 Y  N
    #4 Y  N
    #5 Y  N
    Volume of all others not listed above Y  N
  11. How would you describe your credit ? Great Good Average Poor Bad
  12. Requested limit $/$ Requested deductible $
  13. If accepted by the Insurer what is the requested effective date? 
  14. Has the applicant or any employee of the applicant ever been subject to disciplinary action by any State Agency or Insurance Department? Y N
  15. Have any claims or suits been made against applicant or staff members? YN
  16. 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

    17. By my signing, I am stating all answers in this application are true and complete statements.

     X________________________ 
    Printed Name                             Title                                       Signature                                          Date
Insurance By Design
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