APPLICATION FORM - Consolidated Agency Partners

IBA
APPLICATION FORM
1.
Insured company:
2.
Trading address:
3.
Please state when your company was established:
4.
a)
How many principals / partners / directors are there in the Company?
b)
Please show the details of all principals / partners / directors:
Name
Years in position
5.
Please state the number of employees:
6.
Please state your annual revenue, broken down as follows:
Years experience
Professional:
Years licensed
Other:
Last complete financial year:
Current financial year (estimate):
Premium income
Retained commission/brokerage
Fees
Total revenue
7.
8.
Please provide a breakdown of the business placed by you for the last complete financial year (retail brokers will be 100% retail)
Retail agent/broker:
%
Surplus line broker:
Other:
%
If other please provide details:
10.
%
MGA:
%
%
Commercial lines:
%
Life & Health:
%
Total:
100 %
Please state the percentage of your book of business:
Aviation:
%
D&O liability:
%
Long haul trucking::
%
Reinsurance:
%
Bonds:
%
Errors & omissions:
%
Marine (wet):
%
Workers compensation:
%
Crop coverage:
%
Livestock:
%
Medical malpractice:
%
Preferred provider
organization (PPO):
%
Please confirm that you:
a)
11.
Wholesaler:
Please provide a breakdown of your book of business:
Personal lines:
9.
%
record all business related telephone conversations?
Yes
No
b) document the purpose of the telephone call and the content?
Yes
No
c)
ensure that all employees follow the correct procedures?
Yes
No
d) always confirm in writing in the event a client is declined coverage?
Yes
No
e)
f)
Yes
No
Yes
No
Yes
No
always ask for a written confirmation in the event a client request to reduce their coverage or cancel their policy?
always confirm in writing any delay in the inception of a client’s coverage or any special terms applied to a
client’s acceptance?
Do you hold any binding authorities? (such as an MGA)
If yes, please attach full details including the classes of business, insurers, maximum limits, whether the authority is full or limited, gross premium,
the dates of the last audit and the claims authority limits
CFC Underwriting Ltd is Authorized and Regulated by the Financial Conduct Authority
©2014-2015 CFC Underwriting Ltd, All Rights Reserved
CFC IBA US INTER PACIFIC V1.1
IBA
12.
Please provide details of your current Errors and Omissions insurance, if applicable, and what you require for the next year of insurance:
Retroactive date
13.
Effective date
Current:
MM / DD / YY
MM / DD / YY
Required:
MM / DD / YY
MM / DD / YY
Limit
Deductible
Premium
Insurer
N/A
N/A
Regarding all of the types of insurance to which this application form relates, AFTER INQUIRY:
a) are you aware of any loss or damage, whether insured or not, that has occurred to any of the Companies to be insured (or to any existing
or previous business of the partners or directors of any of the Companies to be insured) within the last 5 years, or
b) are you aware of any circumstances which may give rise to a claim against any of the Companies to be insured or any partners or directors
thereof, or
c) have any claims or cease and desist orders been made against any of the Companies to be insured, or partners or directors thereof, or
d) have any partners or directors of the Companies to be insured been found guilty of any criminal, dishonest or fraudulent activity or
been investigated by any regulatory body?
With reference to questions a, b, c and d above:
Yes
No
If the answer to the above is ‘yes’, then please attach full details including an explanation of the background of events, the maximum amount involved /
claimed, the status of the claim(s) or circumstance(s) and any reserve(s) or payment(s) made by you and / or by Insurers, and the dates of all developments
and payments.
DECLARATION
I / we declare that after proper enquiry the statements and particulars given above are true and that I / we have not mis-stated or
suppressed any material fact.
I / we agree that this Application Form, together with any other material information supplied by me / us shall form the basis of any contract
of insurance effected thereon.
I / we undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract.
Full Name:
Signature:
Position held at Insured:
Date:
MM / DD / YY
Consolidated Agency Partners, Inc.
EMAIL COMPLETED APPLICATION TO:
chris.borchert@cap-1.com
CFC Underwriting Ltd is Authorized and Regulated by the Financial Conduct Authority
©2014-2015 CFC Underwriting Ltd, All Rights Reserved
CFC IBA US INTER PACIFIC V1.1