Agents of United Insurance Group Agency, Inc

Agents of United Insurance Group Agency, Inc.
CalSurance
Enrollment Form
Claims Made & Reporting Errors & Omissions Coverage
Policy Period: October 1, 2009 to October 1, 2010
R
E&O Program Specialists
By purchasing this insurance, agents become members of the Financial Sales Professionals Risk Purchasing Group, a group formed and operating pursuant to the Liability
Risk Retention Act of 1986 (15 USC 3901 et seq.). There is no additional charge for membership.
Instructions........................ Complete ALL sections of this form and include your signature at the bottom.
For Faster Online Enrollment:
Return this form along with payment or Payment Authorization Form (if applicable) to:
www.calsurance.com/uig
If Paying by Credit Card or ACH (Debit to Checking) please fax to: (800) 607-6875.
If Mailing a check send to: Brown & Brown of California, Inc. dba CalSurance Associates*, P.O. Box 7048, Orange, CA 92863-7048
Coverage Questions.............Call Brown & Brown of California, Inc. dba CalSurance Associates* at (800) 745-7189 or email at info@calsurance.com
Reminder...............................ALL sections must be completed. Incomplete forms will take additional time to process. Faxed forms take approximately 3-5 business days to
process. Please allow up to ten (10) business days if mailed.
Certificates of Insurance......Call CalSurance at (800) 745-7189 or
Go on-line: www.calsurance.com - Certificate Reprinting - Sponsoring Group - LTC Global, Inc.
 Section 1 - Your Information (Please Print Clearly)
 Section 3 - Payment Options (Please select one)
Check or Money Order
Payment in Full Only; No Installments
Last Name
First Name
Debit to Checking (Please complete Payment Authorization Form)
Payment in full
Payment in four (4) installments ($7.50 fee per installment)
Street Address
Credit Card (Please complete Credit Card Information below)
Payment in full
Payment in four (4) installments ($7.50 fee per installment)
Mailing Address (if different than street address)
NOTICE: If a payment option is not selected, the selection by default will be
City
State
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Zip Code
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Contact Phone Number
Fax Number
Agent Code
E-mail
payment in FULL.
Please review the installment schedule (included within this enrollment packet) carefully. I
authorize Brown & Brown of California, Inc. dba CalSurance Associates to process the
installment charges according to the installment schedule included within this enrollment
packet. If any of the scheduled installment dates are within 7 days of the date this enrollment
form is processed, the amount due will be divided between the available installment dates. I
also understand that if payment is declined, coverage shall terminate upon ten (10) day
Notice of Cancellation. Payment may be made within the specified ten (10) day period along
with a Decline Processing Fee of $50 to maintain coverage. Should payment be declined a
second time, the entire amount due for the remainder of the policy period will be due in full
within the specified ten (10) day period to maintain coverage.
(Billing through Brown & Brown of California, Inc., dba CalSurance Associates)
Credit Card Information
Discover
Master Card
Visa
Account #: (Please note, Debit Cards or American Express are not accepted!)
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 Section 2 - Effective Date and Amount Due
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Effective Date of Coverage
/
Expiration Date
NOTICE:
Effective date of coverage cannot be prior to your date of contract
with the sponsor and cannot be backdated to a prior month.
Coverage Level*:
(Select One)
Tier I.......Excludes Coverage for Variable Products
and Mutual Funds
Tier II......Includes Coverage for Variable Products
and Mutual Funds
* Please refer to the “Outline of Coverage” for coverage Tier details
Enter amount from PREMIUM TABLE
(included in this packet) which corresponds
to the above selections:
$
(Rates are inclusive of a $30.00 non-refundable administration fee
and 2.25% surplus lines tax/fee.)
UIGApp091609v3
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Cardholder’s Name
Cardholder’s Signature
 Section 4 - Representations and Warranties
I understand and agree to the following: I must be a currently contracted agent with
United Insurance Group Agency, Inc., LTC Global, Inc. or one of its subsidiaries
(Sponsor). Otherwise, I may not be considered an insured under this policy, and
claims made against me may not be covered. Should my contract with the sponsor
terminate for any reason, coverage will continue until the end of the policy period
provided that the premium is paid in full.
This is a claims made and reported policy. I have no knowledge of any pending
claim or incident that could give rise to a claim under the proposed policy, and if any
such claim exists, or knowledge or information exists and any claim or action arises
there from, it is excluded from coverage for which this enrollment form applies. A
potential gap in coverage may occur if I elect an effective date that is not continuous
with my prior expiration date, and may result in denial of a claim.
Signature (Required)
Brown & Brown of California, Inc. dba CalSurance Associates
*(dba CalSurance Brokerage in New York)
California License # 0B02587
Date
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