4 What is the total number of partners, staff, and office brokers?
(If sole proprietor, please list yourself as an owner. Enter N/A for parts a & b.)
6 Percent of business placed as:
(Total must equal 100%. This form requires all fields to be filled -- please write 0 if not applicable.)
7 Please indicate the percentage of Written Premium derived from the following lines:
(Total of ALL lines must equal 100%. This form requires all fields to be filled -- please write 0 if not applicable.)
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The totals in questions 6 & 7 must each equal 100% before you can proceed.
(If this is a new agency, please estimate the written premium and commissions for the next 12 months)
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This is an application for a claims made policy. Except as otherwise provided, the policy will cover only claims first made against the applicant and reported to the insurer during the policy period. Please note that in most policies the limit of liability available to pay damages shall be reduced and may be completely exhausted by payment of claims expenses. Damages and claims expenses shall be applied against the deductible.I/we hereby declare that the above statements and declarations are true and that I/we have not suppressed or misstated any material facts. I/we agree that any misrepresentation or misstatement of material facts may void coverage under the proposed insurance. I/we agree that this application shall be the basis of the contract with the insurer and that coverage, if written, will be provided on a claims made basis. It is understood and agreed that completion of this application neither binds the insurer to provide coverage nor the applicant to purchase the insurance. I/we agree that if the information supplied on this application changes between the date the application is executed and the time the proposed insurance policy is bound or coverage commences, the applicant will immediately notify the carrier in writing of such changes. The carrier reserves its rights to modify or withdraw its proposal following such changes.I/we also understand and agree that I/we have made representations in this application, and have been made aware of the provisions of the proposed policy, as the condition precedent to any coverage that I/we establish and maintain the documentation of communications, transactions, and other aspects of the Professional Activities to be provided coverage. Underwriters expressly state that they are relying on and will only issue any Policy pursuant to this Application in reliance on these agreements and coverage under any Policy issued pursuant to this Application that I/we establish and maintain such documentation at all times as to any and all Professional Activities provided coverage under this Policy. No coverage will be afforded under this Policy in any amounts, including damages and/or claims expenses incurred as to any claim regarding which I/we have failed to establish and maintain such documentation relating to such claim against the Insured.
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