LIFE & HEALTH INSURANCE AGENTS/BROKERS
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Applicant’s Name: Name of Contact Person:
Mailing Address:
City: State: CA   Zip: Proposed Effective Date:
DBA (Doing Business As)
Location Address (If Different From Mailing):
City: State:                   Zip:

Phone: Fax: Email Address:

Applicant is: Sole Proprietorship Partnership Corporation Other

Date first licensed: Life/Health P/C (if applicable) Series 7 (if applicable)

Please check the professional designations you currently hold:

CLU RHU LUTC ChFC CIC
REBC CPCU RPLU Other
Has the applicant been involved with any mergers, purchases or, acquisitions in the past five years? If yes, please describe on a separate sheet.
 Yes No
Has the applicant ever had any professional license terminated or suspended? Yes No
Have any professional liability claims been made against the applicant or any of its past or present owners, officers, partners,employees, or solicitors, or to the knowledge of the applicant on behalf of its predecessors in business, within the last five years? Yes No
Are there any known circumstances or incidents which may result in a professional liability claim? If yes, give details: Yes No

EMPLOYEE INFO

Declarations of “LICENSED” persons, (including yourself), whether owners, partners, directors, officers, or employees (selling or not).
NAME OF LICENSED PERSON
DESIGNATION* CODE
COMMISSIONS LAST 12 MONTHS

COMMISSIONS NEXT 12 MONTHS
Total Number of sub-agents, brokers, and independent contractors:

Total Commissions . . . . . . . . . . . . .
*Designation Codes: O = Owner P = Partner OF = Officer/Director E = Employee (if necessary, use separate sheet)
Unlicensed Staff: Total Number Full Time: Part Time:

Please note that the policy covers the applicant for any liability resulting from the actions of independent contractors so long as the revenues from independent contractor(s) are indicated above.
Do you verify that all non-employed sub-agents/independent contractors are required to carry Errors and Omissions Coverage?
 Yes No

REVENUE

Please indicate percentages of the applicants revenue derived from each line of business written below: The total of all lines should equal 100%
% Life–Individual  % A&H–Individual % Stocks % RIA/Financial Planning 
% Life–Group     % Bonds  % A&H–Group      % Property/Casualty Products
% Fixed Annuities  % Mutual Funds    % Variable Annuities % All Other

Does the applicant require coverage for property casualty production?............
(If Yes, additional premium will apply.)

 Yes No
Does the applicant require coverage for Financial Products (Mutual Funds and Variable Annuities) production?........ (If Yes, additional premium will apply.)
Yes No

Does the applicant require coverage for Investment Services production?
(Stocks, Bonds, RIA/Financial Planning) ...... (If Yes, additional premium will apply.)

 Yes No 
Does the applicant place coverage or have involvement with Self Insured/Captives or Risk Retention Groups (RRG), Risk Purchasing Groups (RPG), Mutiple Employer Trusts (MET), or Multiple Employer Welfare Arrangements (MEWA)? ........
If yes, please provide a brief description
Yes No

List the top five Insurance Companies with which you place business
Name of Insurance Company
Products Sold
% of Revenues

Do you currently have Errors and Omissions Insurance in Force? ..........

Yes No
If Yes, what is: Name of Insurer Expiration Date:

Retroactive Date: Current Limits $ Deductible $ Premium $

NOTE: Prior Acts coverage may only be available if the applicant has had continuous coverage in force with no gaps. If the applicant has not carried coverage or is not able to provide proof of coverage, the retroactive date of the policy will be inception. If “Yes”, proof of prior coverage will be required.
Do you wish to purchase prior acts coverage?...............
Yes No
Limits of liability desired $ Deductible amount desired $
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.