APPLICANT INFORMATION
 
* Required
  
   
* Full Legal Name:
* Street Address:
* City:
* State:
 
(NY agents may not use this application. Please call MARSH at (888) 424-2310.
* Zip:
* Email Address:
* Phone:
Fax: xxx-xxx-xxxx
Web Site Address:
* Ownership Type: Individual
Parternship
Corporation
LLC
LLP
Other
   
* Date Established: (mm/dd/yyyy)
   
* Do you have any subsidiaries or branch offices? Yes No
   
* Are you a member of NAHU? Yes No
If yes, please provide
member name:
   
* Are you a member of any other
insurance professional organization?		 Yes No
If yes, describe:
   
* During the past five (5) years,
has any portion of your business or
operations been sold or transferred to
another person or business entity?		 Yes No
   
* Are you engaged in any other
business operations, or do you
conduct business under any other name?		 Yes No
   
* Are you affiliated with, associated with, controlled by or represent any
other agency, Brokerage or
agency cluster type arrangement?		 Yes No
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BUSINESS BREAKDOWN
Provide the gross annual commission and fee revenue from life and health products and services provided by your agency (revenue is based on commission income and fees before deduction of expenses). Include commission or fee revenue from mutual funds only if you are requesting this optional coverage.
* For the past 12 months:
* Estimated revenue for next year:
   
* Give the approximate percentage breakdown of the total business
that is placed by you or your agency:
Agent (Personal Producing):

%
Broker (Personal Producing): %
Consultant (for fee): %
Other: %
   
* Break down your total revenues by percentage of professional activities during the past year. Total must equal 100% of total gross revenues:
“FULLY INSURED” Life and annuity policies (individual and group) issued by
licensed Life Companies:		 %
“FULLY INSURED” Health, A&H and Medical policies (individual and group) issued by licensed
Life/A&H Companies, Regulated HMOs
or Service Plans (Blue Cross/Shield): 		%
Mutual Fund Sales (exclusive of Annuity/Group or Employee Benefit plans): %
Any other business activity: %
   
* Full Names of Life/Accident & Health Companies and percent of total business with each:
1st company: %
2nd company: %
3rd company: %
4th company: %
5th company: %
Total of all other companies: %
  (If more than 30%, the underwriting department will contact you at a later date.)
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PRODUCTION SOURCES
Provide the dates you were first licensed and the professional designation(s) you hold:
* Name of Licensed Individual:
Life Date: (mm/yyyy)
A&H Date: (mm/yyyy)
SEC (type/series#):
Professional Designations Held:
   
* Indicate the number of unlicensed
support staff in your office:
   
Indicate the percentage of your total business received:
Direct from your Insureds: %
From other agents, brokers or
non-employee producers who
receive payment from you or from
your carriers for this business:		 %
   
* List all states where
licenses are held by you:
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LOSS CONTROL
* Do you maintain a written
office procedure manual?
* If yes, does it contain the following?  
Procedures for handling all business transactions: Yes No
File documentation requirements: Yes No
Agency diary and recall procedures: Yes No
Job descriptions/responsibilities for each employee: Yes No
Guidelines for carrier ratings: Yes No
Company Information: Yes No
Agency statement regarding training and education: Yes No
Role of the computer in the agency: Yes No
   
* Have you attended a Sponsored
Loss Control Seminar in the past 12 months? (NAHU, NAIFA, PIA, IIA)		 Yes No
  (If yes, a copy of your Seminar Attendance Certificate will be requested later by the underwriting department.)
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CURRENT PROFESSIONAL LIABILITY COVERAGE
  (A copy of your last Declarations Page will be requested later by the underwriting department.)
 
* Carrier
* Policy
Expiration Date
* Limits
* Deductible
Annual Premium
* Did coverage
include all
Products & Carriers?
* 1
Yes No
2
Yes No
3
Yes No
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(mm/dd/yyyy)
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PAST PROFESSIONAL LIABILITY CLAIMS/LOSS HISTORY
* Have you been the subject of any
fines or disciplinary action by any
insurance or other regulatory authority?		 Yes No
   
* Has any policy or application for professional liability insurance on behalf of the applicant, or to your knowledge on behalf of any preceding insurance related business of yours, ever been declined, canceled
or renewal refused within the past 10 years?		 Yes No
  (Not applicable if domiciled in Missouri.)
   
* Have any professional liability claims
been made against the applicant,
or to the knowledge of the applicant,
on behalf of any preceding business
of yours, within the past 5 years?		 Yes No
  (If yes, please go to the Forms page of our website and print the Supplemental Claim Form. Complete the form and FAX TO: (515) 243-2331.)
   
* Are there any circumstances which
may result in professional liability claims being made against the applicant or any preceding business of yours?		 Yes No
  (If yes, please go to the Forms page of our website and print the Supplemental Claim Form. Complete the form and FAX TO: (515) 243-2331.)
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COVERAGE DESIRED
Please check the coverage limits and desired deductible:
(Note: the $100,000/$300,000 limit option and $1,000 deductible is only available to firms with revenue
less than $75,000. Availability of some Limit and Deductible options may be subject to underwriting and
regulatory restrictions).
   
   
* Coverage Limits
   
* Deductible
 
$100,000/$300,000
$1,000 (minimum)
 
$250,000/$750,000
  
$2,500
 
$500,000/$1,500,000
  
$5,000
 
$1,000,000/$3,000,000
  
$7,500
 
Other
 
$10,000
 
   
Other
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* Is coverage desired for
the sale of Mutual Funds?		 Yes No
 
(Coverage for Mutual Fund sales can be added
to the policy for an additional premium charge)
   
   
Please include a sample of your stationery letterhead with this application.
   
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