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Insurance Agents & Brokers E&O Application

NOTICE

Insurance agents and brokers errors and omissions policies are generally written on a claims-made basis: only claims first made during the policy period (and reported as the policy requires) are covered. This application is not a binder.

Prefer paper? Download the printable PDF · Questions? Call (469) 777-3025 or email contactus@proiexp.com.

"*" indicates required fields

Step 1 of 8 – Applicant & Contact Information

12%

Please type directly into the fields. Every question must be answered; respond "N/A" to any question that does not apply. If a whole section does not apply, choose its N/A option and skip to the next section. Insurance agents E&O policies are generally written on a claims-made basis: only claims first made during the policy period (and reported as the policy requires) are covered. This application is not a binder.

1. Applicant & Contact Information

Applicant legal name*

DBA(s) / trade names

Website

Physical street address*

Address City State Zip Code

County

Mailing address (if different)

Address City State Zip Code

Phone*

Email*

Contact name*

Contact title

Entity type

Corporation

LLC

Partnership / LLP

Sole Proprietor

Other

Entity type – other (describe)

Year established

FEIN (optional)

Years of industry experience of the principal(s)

Please enter a number greater than or equal to 0.

Number of locations

Please enter a number greater than or equal to 0.

State where most income is produced

Other states licensed / doing business

Past names / DBAs / entities (needed for prior acts)

Professional associations / trade groups (e.g. IIABA, PIA, NAIFA)

During the last 3 years, has there been a change in agency name or ownership, or an acquisition or merger of an agency or book of business?

Yes

No

Is the applicant owned by, controlled by or affiliated with any other firm, including an insurance company?

Yes

No

Is coverage needed for any subsidiary, affiliate or DBA in addition to the applicant?

Yes

No

If yes to any, please give names and details

2. Owners, Staff & Producers

Owners, partners, officers and principal producers

Name

Title

Ownership %

Years in insurance

Licenses / designations (CPCU, CIC, CLU…)

Licensed producers

Please enter a number greater than or equal to 0.

CSRs / account managers

Please enter a number greater than or equal to 0.

Other staff

Please enter a number greater than or equal to 0.

Independent contractors / sub-producers

Please enter a number greater than or equal to 0.

% of sales staff with professional designations

Are all employees who have customer contact licensed?

Yes

No

Do any producers have personal production outside of business placed through the agency?

Yes

No

Independent contractors to be covered

All ICs

Only ICs exclusive to the agency

Separate limits

N/A – no ICs

Do you require proof of E&O insurance from sub-agents, sub-brokers and contractors who place business through you?

Yes

No

N/A

Is the applicant a captive or exclusive agent, or employed by an insurance company?

Yes

No

Would you like a quote for employment practices liability (EPLI)?

Yes

No

3. Coverage Requested & Insurance History

Desired effective date

Requested retro date

Limits (per claim / aggregate; check each to quote)

$500K/$500K

$500K/$1M

$1M/$1M

$1M/$2M

$2M/$2M

$2M/$4M

$3M/$3M

$5M/$5M

Other

Limits (per claim / aggregate; check each to quote) – other (describe)

Deductible (check each to quote)

$1,000

$2,500

$5,000

$10,000

$25,000

Other

Deductible (check each to quote) – other (describe)

Defense costs

Inside the limit

Outside the limit (if available)

Quote both

Also quote (optional; check each that applies)

Cyber / data breach

Crime / social engineering

General liability / BOP

Employment practices (EPLI)

Does the applicant have insurance agents E&O insurance in force now? (New firms: answer No.)

Yes

No

Current and prior policies, last 5 years (current policy first; write "none" for any year without coverage)

Insurer

Policy period (from – to)

Limits

Deductible ($)

Premium ($)

Retro date

Has the applicant ever purchased an extended reporting period ("tail") from a prior insurer, or had a gap in coverage?

Yes

No

Does the applicant want an additional insured endorsement for any contract that requires one?

Yes

No

4. Revenue & Business Mix

Use the past 12 months. If newly established, estimate the next 12 months. Commission and fee income is after payments to non-exclusive sub-producers.

Property & casualty – Premium volume ($)

Please enter a number greater than or equal to 0.

Property & casualty – Commission & fee income ($)

Please enter a number greater than or equal to 0.

Property & casualty – Projected next 12 months ($)

Please enter a number greater than or equal to 0.

Life, health & financial products – Premium volume ($)

Please enter a number greater than or equal to 0.

Life, health & financial products – Commission & fee income ($)

Please enter a number greater than or equal to 0.

Life, health & financial products – Projected next 12 months ($)

Please enter a number greater than or equal to 0.

Fee income (consulting, TPA, other) – Premium volume ($)

Please enter a number greater than or equal to 0.

Fee income (consulting, TPA, other) – Commission & fee income ($)

Please enter a number greater than or equal to 0.

Fee income (consulting, TPA, other) – Projected next 12 months ($)

Please enter a number greater than or equal to 0.

TOTAL – Premium volume ($)

Please enter a number greater than or equal to 0.

TOTAL – Commission & fee income ($)

Please enter a number greater than or equal to 0.

TOTAL – Projected next 12 months ($)

Please enter a number greater than or equal to 0.

Retail agent %

Please enter a number from 0 to 100.

Wholesale broker %

Please enter a number from 0 to 100.

MGA / MGU / program %

Please enter a number from 0 to 100.

Other %

Please enter a number from 0 to 100.

% of commission income by line (all three columns together should total 100%)

Auto – standard – %

Please enter a number from 0 to 100.

Package / BOP / property – %

Please enter a number from 0 to 100.

Individual life (term / permanent) – %

Please enter a number from 0 to 100.

Auto – non-standard – %

Please enter a number from 0 to 100.

GL / excess / umbrella – %

Please enter a number from 0 to 100.

Indiv. health / disability / LTC – %

Please enter a number from 0 to 100.

Homeowners / dwelling / fire – %

Please enter a number from 0 to 100.

Commercial auto (non-trucking) – %

Please enter a number from 0 to 100.

Medicare supplement / Advantage – %

Please enter a number from 0 to 100.

Flood – %

Please enter a number from 0 to 100.

Trucking / long-haul – %

Please enter a number from 0 to 100.

Group life / health / dental – %

Please enter a number from 0 to 100.

Umbrella – %

Please enter a number from 0 to 100.

Workers compensation – %

Please enter a number from 0 to 100.

Self-funded / stop loss – %

Please enter a number from 0 to 100.

Boats / RV / recreational – %

Please enter a number from 0 to 100.

Professional / D&O / cyber – %

Please enter a number from 0 to 100.

Fixed / indexed annuities – %

Please enter a number from 0 to 100.

Other personal (describe)

Other personal – %

Please enter a number from 0 to 100.

Medical malpractice – %

Please enter a number from 0 to 100.

Variable products / securities – %

Please enter a number from 0 to 100.

Inland / ocean marine – %

Please enter a number from 0 to 100.

Other L&H / financial (describe)

Other L&H / financial – %

Please enter a number from 0 to 100.

Bonds – surety / fidelity – %

Please enter a number from 0 to 100.

Crop / farm / livestock – %

Please enter a number from 0 to 100.

Aviation – %

Please enter a number from 0 to 100.

Other commercial (describe)

Other commercial – %

Please enter a number from 0 to 100.

% billed by agency

% direct billed

% via carrier service center

% of premium with non-admitted / surplus lines

% with state workers comp funds / JUA / pools

% placed with carriers not rated or rated below B+ by A.M. Best

Top carriers / markets (largest first)

Carrier / wholesaler

Line(s)

% of income

Admitted? (Y/N)

Direct contract? (Y/N)

Years represented

Does the applicant specialize in any program or class of business (e.g. trucking, contractors, habitational, oil & gas, auto dealers)?

Yes

No

If yes, describe the class(es) and % of income

Do you expect major changes in the lines of business you write in the next 12 months?

Yes

No

5. Special Exposures & Other Services

Does the applicant have binding, underwriting or claims authority from any carrier (MGA / MGU / program administrator)?

Yes

No

In the last 5 years, has any program or contract been cancelled, terminated or had its authority restricted?

Yes

No

N/A

Does the applicant place, form, manage or administer captives, risk retention or purchasing groups, PEOs, self-insured plans or trusts, METs or MEWAs?

Yes

No

Does the applicant sell variable products, securities or mutual funds, or give investment or financial-planning advice?

Yes

No

Is the applicant involved in life settlements, viaticals, premium-financed life, STOLI or structured settlement annuities?

Yes

No

Does the applicant act as a named fiduciary or have discretionary control of any client's assets?

Yes

No

Does the applicant receive override commissions or fees for recruiting, licensing or marketing for an insurer?

Yes

No

If yes to any of the above, please explain

Other services: check any the applicant, owners or employees perform, and give annual revenue

Premium finance – Revenue ($)

Please enter a number greater than or equal to 0.

Third-party administration (TPA) – Revenue ($)

Please enter a number greater than or equal to 0.

Claims adjusting – Revenue ($)

Please enter a number greater than or equal to 0.

Reinsurance intermediary – Revenue ($)

Please enter a number greater than or equal to 0.

Risk management / loss control / OSHA audits – Revenue ($)

Please enter a number greater than or equal to 0.

Human resources / benefits consulting – Revenue ($)

Please enter a number greater than or equal to 0.

Actuarial services – Revenue ($)

Please enter a number greater than or equal to 0.

Tax preparation / accounting – Revenue ($)

Please enter a number greater than or equal to 0.

Real estate sales – Revenue ($)

Please enter a number greater than or equal to 0.

Notary / prepaid legal – Revenue ($)

Please enter a number greater than or equal to 0.

Other (describe)

Other – Revenue ($)

Please enter a number greater than or equal to 0.

6. Office Procedures & Information Security

Does the agency use an agency management system for all policies, notes and diaries?

Yes

No

Is there a written office procedures manual that is reviewed at least once a year?

Yes

No

Are incoming documents and requests date-stamped, and is there a diary / suspense system for follow-up?

Yes

No

Are phone calls, coverage instructions and agreements with clients documented in the file?

Yes

No

Are policies, endorsements and binders checked against the application and the client's request before delivery?

Yes

No

Does the agency document the client's acceptance or written rejection of offered coverages and limits (e.g. flood, umbrella, UM/UIM, cyber)?

Yes

No

Are written, signed confirmations obtained when a client reduces or removes coverage?

Yes

No

Are expiration lists used, and are renewals marketed and quoted in time before expiration?

Yes

No

Are exclusions and special deductibles (e.g. wind, hurricane, earthquake, mold, cyber) disclosed to clients in writing?

Yes

No

Are certificate holders tracked so they are notified of cancellation or material changes when required?

Yes

No

Is premium kept in a separate premium trust account?

Yes

No

For a one-person agency: is there a back-up plan if the owner is unavailable?

Yes

No

N/A

% of staff who attended an E&O loss-prevention seminar in the past 24 months

Has the agency had an E&O audit, and were the recommendations put in place?

Yes

No

N/A

Does the applicant use multi-factor authentication for email and remote access, and keep regular offline backups?

Yes

No

Are laptops and devices that store client personal information encrypted, with firewall and anti-virus kept up to date?

Yes

No

Are changes to payment or wire instructions always verified by phone before money is sent?

Yes

No

Approximate number of client records (SSN, health, financial) held

Please enter a number greater than or equal to 0.

In the last 3 years, has the applicant had a data breach, ransomware attack or funds-transfer fraud?

Yes

No

Please explain any "No" answer in this section

7. Claims & Disciplinary History

In the last 5 years, has any E&O or cyber claim or suit been made against the applicant, a predecessor or anyone proposed for insurance?

Yes

No

Does anyone proposed for insurance know of any act, error, omission or circumstance that could result in a claim?

Yes

No

In the last 5 years, has the applicant made an "adjustment" or goodwill payment to settle a client dispute?

Yes

No

In the last 5 years, has the applicant or anyone proposed for insurance been the subject of a complaint, investigation, fine, license suspension or other action by an insurance department or other regulator?

Yes

No

Has any carrier terminated the applicant's contract or appointment for cause, or has the applicant sued a carrier?

Yes

No

Has any owner, officer or employee been convicted of a felony, or has the applicant been in bankruptcy?

Yes

No

In the last 3 years, has any insurer declined, cancelled or non-renewed E&O insurance for the applicant (other than an insurer leaving the market)? Not applicable in Missouri.

Yes

No

Claim / Circumstance Details

If you answered Yes to a claim or circumstance question above, give the details for each one.

Claim or incident 1

Claim 1 – what happened (description)

Claim 1 – date of claim or incident

Claim 1 – reported to the insurance carrier?

Yes

No

Claim 1 – status

Open

Closed

Claim 1 – amount paid ($, if known)

Please enter a number greater than or equal to 0.

Is there a second claim or incident to report?

Yes

No

Claim or incident 2

Claim 2 – what happened (description)

Claim 2 – date of claim or incident

Claim 2 – reported to the insurance carrier?

Yes

No

Claim 2 – status

Open

Closed

Claim 2 – amount paid ($, if known)

Please enter a number greater than or equal to 0.

Is there a third claim or incident to report?

Yes

No

Claim or incident 3

Claim 3 – what happened (description)

Claim 3 – date of claim or incident

Claim 3 – reported to the insurance carrier?

Yes

No

Claim 3 – status

Open

Closed

Claim 3 – amount paid ($, if known)

Please enter a number greater than or equal to 0.

More than 3? List the others in the comments box below. Disclosing a claim does not mean it is covered. Circumstances that could lead to a claim must also be reported to your current insurer before its reporting period ends.

8. Comments, Applicant Statement & Signature

Attachments (optional)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 10 MB, Max. files: 10.

Please attach, if available: the current E&O declarations page and 5 years of loss runs.

Additional comments or details for any "Yes" answer

Applicant Statement & Signature

The undersigned, an authorized owner, partner or officer of the applicant, declares that the statements in this application and any attachments are true and complete to the best of his or her knowledge after reasonable inquiry of all persons proposed for this insurance. If any information changes before the policy effective date, the applicant will promptly notify us, and any quote or binder may be changed or withdrawn. Signing this application does not bind the applicant or any insurer to complete the insurance, but if a policy is issued, the insurer will rely on this application and it will become part of the policy. Nothing in this application is notice of a claim or potential claim under any policy. The applicant authorizes this information to be shared with insurance companies for the purpose of obtaining quotes.

Fraud Statements

Fraud Statement (All States, including Arkansas, Louisiana, Rhode Island and West Virginia): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. A binder may not be withdrawn but a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicant statement*

I have read and agree to the Applicant Statement and Fraud Statements above.

Signature*

Your Name
Your Name
Your Name

Date*

Printed name*

Signer title

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