MGA LLC or Trust Questionnaire

Note: We have been quoting / writing Hudson CPL Policies through the wholesaler (3rd party) JE Brown. We will now be placing the policy through a different wholesaler Personal Umbrella.com. Here are the steps to follow.

Step 1: To get a quote, complete this application and email it to the underwriter Cyndy(cnyquist@mymga.com).
Signatures are not required to get a quote. You will receive the formal quote in a few days.

Step 2: If the client wants the purchase the policy, then have the client sign the proposal and application and email it to the
underwriter Mary Nyquist (mnyquist@mymga.com).

Step 3: Since this is a direct bill policy, then we do not need to collect any money at all. The client will receive a copy of the
policy along with the invoice.

Person Completing form*

The completed PDF form will be emailed to the email address associated with this person

Today's Date*

Date

Completed By (For Email Subject Line)*

Client Info:

What is the Name Insured*

What is the Type of Entity*

Is the Entity different than Name Insured*

What is the Entity Name*

Mailing: Address*

City*

State*

Zip*

List all Entity Members, Trustees or Executors (Separated by Comma)

What is the purpose of the formation of the entity*

Please Explain*

Tax Purposes (Mapping)*

Real Estate Investments (Mapping)*

Manage Properties (Mapping)*

Individual Asset Protection (Mapping)*

Other (Mapping)*

How many exposures owned by this Entity

Exposures In whole or in part

Exposure 1: Address*

City*

State*

Zip*

Percent Owned*

Usage/Occupancy*

Exposure 2: Address*

City*

State*

Zip*

Percent Owned*

Usage/Occupancy*

Exposure 3: Address*

City*

State*

Zip*

Percent Owned*

Usage/Occupancy*

Exposure 4: Address*

City*

State*

Zip*

Percent Owned*

Usage/Occupancy*

Additional Information:

Has the purpose of the entity changed since its formation?

Yes (Mapping)*

No (Mapping)*

Within the past five years, has the entity engages in any form ofbusiness or owned any real estate for business purposes whether ornot identified on the application?

Yes (Mapping)*

No (Mapping)*

In the past five years, has the entity been the subject of any kind oflitigation?

Yes (Mapping)*

No (Mapping)*

Does the entity have any employees?

Yes (Mapping)*

No (Mapping)*

Does the entity own any real estate, personal property or assets notlisted on the application?

Yes (Mapping)*

No (Mapping)*

Provide Additional Information to any "Yes" response(s):

Enter here any Additional Information: