Your profession or industry

Requested effective date

Other than the business address provided above, how many additional locations does your business own or rent

What best describes your business's ownership structure

Do you currently have an insurance policy in effect for the coverage requested?

Please provide the name of your insurance carrier:

Do you have the retroactive date of your current Professional Liability policy?

Does your business provide any of the following services?

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• Actuarial advice

• Financing or financial auditing

• Investment or tax advice

• Legal advice

• Lobbying and/or political advice

• Medical advice

• Mergers and acquisitions or business valuations

Does your business provide services in the capacity of the following?

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• Managing General Agent (MGA)

• Managing General Underwriter (MGU)

• Professional Employer Organization (PEO)

• Program administrator or Third Party Administrator (TPA)

• Reinsurance intermediary

• Risk Retention Group (RRG)

• Wholesale broker

• Health Maintenance Organization (HMO) plan creator, manager and/or administrator

Does your business provide insurance placement or advice for any of the following insurance products or services?

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• Aviation insurance

• Lawyer’s liability insurance

• Mining insurance

• Multiple Employer Welfare Arrangements (MEWA)

• Variable annuities, mutual funds, stocks, or investment bonds

• Variable life insurance

Does your business perform an annual account review with each of your clients?

What type of insurance placement services does your business provide?
(check all that apply)

Approximately when did your business begin?

If required by state law, do you or the principal of your firm maintain current and valid professional training, certifications, licenses or designations for all services you provide?

For the next 12 months, what is your business’s estimated total annual revenue (from commissions and other sources of revenue)

Requested policy limits and deductible

Aggregate Limit

Deductible