Crop Agent's E&O INSURANCE BROKER’S PROFESSIONAL INDEMNITY INSURANCE APPLICATION FORM (THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY)
NOTE: In applying for the coverage, the applicant understands that in the event of an insured loss, the limit of liability and deductible shall be inclusive of the loss payment and the claim expenses as defined in the policy.
INSTRUCTIONS:
  1. Please answer all questions, leave no blank spaces.
  2. If space is insufficient to answer fully any answers, attach separate sheet
  3. Application must be signed and dated by owner, partner or officer.

Address of Head Office

2. Address(es) of Branch Offices

2. Address(es) of Branch Offices

5. During the past five years:

6. What is the total number of partners, staff and office brokers?

7. Is the firm licensed (where necessary) or doing business as:

8. Is applicant involved in any of the following activities. If “yes,” please show percentage of total revenue received from each activity:

PLEASE NOTE THAT NO COVERAGE IS GRANTED FOR THESE ACTIVITIES UNLESS SPECIFICALLY AGREED BY ENDORSEMENT TO THE POLICY.

9. What is the annual percentage breakdown by line of business of the applicant’s annual premium income?

9. P)

9. Q)

9. R)

9. S)

10. Does the applicant place business with Lloyd’s Underwriters? If “yes,” please give the approximate percentage of your total commission/brokerage derived therefrom:

10. A)

10. B)

11. What percentage of the applicant’s business is:

12. During the applicant’s last financial year what was:

13. List the top four insurance companies by premium income with which you place business and show the dollar volume for each:

13. A) Insurance Company 1

13. B) Insurance Company 2

13. C) Insurance Company 3

13. D) Insurance Company 4

14.

20. Please give full particulars of all similar insurances during the past five years:

25.

I/we hereby declare that the attached statements and particulars are in all respects true and are material to the issuance of insurance herein and that i/we have not omitted or suppressed or mis-stated any facts and i/we agree that this proposal form shall be the basis of the contract and shall we be deemed a part of the policy as if annexed thereto. Signature of this form does not bind the firm or the underwriters to complete the insurance.

GSC/INSBKRAPP/002

(A copy of your application will be automatically emailed to you once you click the submit button.)