1. Applicant's name as appears on license  
2. Business name (dba)  
   Is business name on record with Insurance Department? Y N
3. Street Address
   City  State  Zip 
4. Any branch offices?  Y N Number of Offices 
5. Phone  Fax  Email 
6. Application is Individual  -    Partnership   Corporation   Other
7. How would you describe your credit?   Great   Good   Average   Poor   Bad
8. Date Agency was established (as applicant's current business name)
   
   
9. List all owners/officers and their percent of ownership interest. Attach copy of all licenses.
   

   Name	% of Ownership	Years Ins. Experience	Years Licensed

10. Is applicant engaged in any other business other than Insurance? Y   N
    If yes, explain
11. Is applicant controlled, owned, affiliated or associated with any other firm, agency, Corporation or Insurance Company ? Y   N   
    If yes, explain
12. During the past 3 years has the name of the Agency been changed or has any other business or Agency been acquired, merged into or consolidated with the applicant? Y   N
    If yes, explain
13. E & O policy currently in force ? Y   N  
    Expiration Date    Retroactive Date
14. List last three E & O carriers. If none state NONE
    

    Carrier	Policy Period	Limit	Deductible	Premium

15. Has the applicant ever had an E & O policy declined, renewal refused, or canceled? ( this also includes nonpayment of monthly payment)   Y   N
    If yes, explain
16. What percentage of volume is standard ?  %  Nonstandard?  %
17. What percent of volume is admitted ?  %  Non admitted?  %
18. Commission income by area of written premium. (combined total should be 100% )
    P&C personal lines %   P&C commercial lines %   Life and Health %
19. What was the total Premium Volume all lines all companies ?
    Last Year $   This Year $   Next Year (est) $
20. What was the total commission income all lines all Companies?
    Last year $   This Year $   Next Year (est) $
21. List volume last 12 months by Ins. Co. or General Agent starting with largest first.
    

    Insurance Company or General Agent	Volume	Admitted	Rating
    #1		Y  N
    #2		Y  N
    #3		Y  N
    #4		Y  N
    #5		Y  N
    Volume of all others not listed above		Y  N

    Combined total volume for this listing should be the same as last year's volume shown in question 19.
    
    
22. What is the percent of applicant's annual commission income by line of coverage ?
    

    Personal	Commercial	Life, A&H
    % Automobile	% Automobile	% Life
    % Homeowners	% Fire	% Health
    % Cycle	% Package	% Accident
    % Boat	% Workers Comp	% Other
    % Other	% Other

23. What percent of your volume is received direct from your insureds ? %
24. Is all incoming mail date stamped and worked every business day ?   Y   N
25. How long do you maintain your records ?
26. Do you give written binders to your insureds ?   Y   N
27. How and when do you notify the insurer of your binding (if allowed) them to a risk?
    Explain 
28. Do you record and document for the file all business related conversations ?   Y   N
29. Do you require a form of written request from your insureds who desire their coverage to be increased, reduced or eliminated ?   Y   N
30. Do you advise insureds of all lines of coverage ?   Y   N
    If no, why not?
31. Are investigations made under provision of the Fair Credit Reporting Act ?   Y   N
32. If accepted by the Insurer, what is the requested effective date? 
33. Requested limit $/$ Requested deductible $
    NOTE: An answer of YES to any of the next three questions will require a written answer in complete detail on the Applicant's letterhead and must be attached to the application.
    
34. Has the applicant or any employee of the applicant ever been subject to disciplinary action by any State Agency or Insurance Department?   Y   N
35. Have any claims or suits been made against applicant or any staff member?   Y   N
36. After inquiry of each person proposed for insurance, is the applicant AWARE of ANY circumstance, omission, error or offense which may result in a claim being made against the applicant or any of applicant's employees?   Y   N 
37. If the answer to 34, 35, or 36 is YES, please explain
    
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I certify that I have read the questions above, and have answered each truthfully and completely to the best of my knowledge

I further herein certify that I understand and agree as follows:

1. This is a CLAIMS MADE policy form, and any claim or suspected claim must be reported during the policy period for coverage to be in effect.
2. Each and every loss shall be subject to the DEDUCTIBLE stated in the policy declarations.
   
3. Coverage is only in effect for the TYPE OF BUSINESS stated in the declarations.
4. Any material misrepresentations, failure to disclose material facts, or failure to disclose any pre-existing condition or incident may result in denial of coverage and/or rescission of the policy by the company.
5. The policy contains EXCLUSIONS for situations not intended for coverage by the company, and it is the responsibility of the applicant to read the policy.