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Agent Broker Carrier Insurance document sample
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P.O. Box 30527
Phoenix, Arizona 85046
(602) 494-6900 (800) 228-1710
Fax (602) 494-6999
HOME-BASED BUSINESS PROGRAM
Underwritten by Occidental Fire & Casualty
Applicant's Name: Producer's Name:
Address: Address:
City,State,Zip: City,State,Zip:
Business Phone: Phone: Fax:
Location Address (if different from mailing):
Effective Date (mm/dd/yy): Please provide requested Policy Inception Date
Legal Entity of Applicant?
Business Description: How Long in business?
UNDERWRITING QUESTIONS:
1. Have you had any Losses in the past 3 Years with Paid or Reserved Amounts >$5,000 in total?
2. Are Sub-Contractors Used in your Business?
3. Do you have Annual Sales greater than $2,000,000?
4. Do you have more than 1 Employee (other than the Owner of the Business)?
5. Is this the only Business Operation that is operating out of the residence?
6. Do you Re-label any Manufacturer's Products that you represent?
PREVIOUS CARRIER INFORMATION
Previous Carriers (Past 3 Years) Has any company ever canceled or refused renewal?
1.
2.
3.
PREVIOUS LOSSES
PRESENT YEAR LAST YEAR SECOND PRIOR YEAR
Type of Loss Amount Paid Type of Loss Amount Paid Type of Loss Amount Paid
d9be64dc-4593-4be4-a979-028475ded494.xls Page 1 of 5 Vers. 03/09
P.O. Box 30527
Phoenix, Arizona 85046
(602) 494-6900 (800) 228-1710
Fax (602) 494-6999
HOME-BASED BUSINESS PROGRAM
Underwritten by Occidental Fire & Casualty
COVERAGE OPTIONS
A1 A2 A3 B1 B2 B3 C1 C2 C3
GL (Occurrence Limit with 2x Agg) $300,000 $300,000 $300,000 $500,000 $500,000 $500,000 $1,000,000 $1,000,000 $1,000,000
PROPERTY (BPP Only) $3,500 $5,000 $10,000 $3,500 $5,000 $10,000 $3,500 $5,000 $10,000
INLAND MARINE $1,500 $2,000 $2,500 $1,500 $2,000 $2,500 $1,500 $2,000 $2,500
TERRORISM COVERAGE Included Included Included Included Included Included Included Included Included
RISK PREMIUM $330 $345 $367 $365 $382 $403 $502 $516 $537
POLICY FEE $30 $30 $30 $30 $30 $30 $30 $30 $30
TOTAL PREMIUM $360 $375 $397 $395 $412 $433 $532 $546 $567
COVERAGE REQUESTED
Loss Payee / Lessor
Name:
Address: Additional Insured or Cert Holder Only?
City,State,Zip:
APPLICANT UNDERSTANDS THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, CORRECT AND COMPLETE
MATERIAL REPRESENTATIONS TO THE COMPANY AND APPLICANT REQUESTS THE COMPANY TO ISSUE THE
INSURANCE POLICY IN RELIANCE HEREON.
Signature of Agent/Broker APPLICATION IS NOT COMPLETE. Date:
PLEASE ENSURE ALL QUESTIONS ARE
Signature of Applicant ANSWERED BEFORE SUBMITTING. Date:
d9be64dc-4593-4be4-a979-028475ded494.xls Page 2 of 5 Vers. 03/09
POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM
INSURANCE COVERAGE
You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have a right
to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1)
of the Act: The term “act of terrorism” means any act that is certified by the Secretary of the Treasury—in
concurrence with the Secretary of State, and the Attorney General of the United States—to be an act of
terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have
resulted in damage within the United States, or outside the United States in the case of an air carrier or
vessel or the premises of a United States mission; and to have been committed by an individual or
individuals as part of an effort to coerce the civilian population of the United States or to influence the
policy or affect the conduct of the United States Government by coercion.
YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSES
RESULTING FROM CERTIFIED ACTS OF TERRORISM SUCH LOSSES MAY BE PARTIALLY
REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY
FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT
AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS
FORMULA, THE UNITED STATES GOVERNMENT GENERALLY PAYS 85% OF COVERED
TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE
INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS
COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION
OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.
YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED,
CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL
AS INSURERS’ LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM
WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION.
IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR
COVERAGE MAY BE REDUCED.
Acceptance or Rejection of Terrorism Insurance Coverage
I hereby elect to purchase Terrorism coverage for a prospective premium of
$____________________
I hereby decline to purchase Terrorism coverage. I understand that I will have no
coverage for losses resulting from acts of terrorism.
Occidental Fire & Casualty
Policyholder / Applicant's Signature Insurance Company
Print Name Policy Number
Date
TRIA 01 08
Nevada Surplus Lines Association
DECLINATION DETAIL
This form is to be used when the policy provides insurance for coverage that cannot be written with admitted insurers.
(Category is not listed on open lines eligible for export.) In pursuant of 685A.215 of NRS, identify three admitted
insurers marketing the class of insurance that declined the risk. Include with this submission form NSLA101.
NAME OF INSURED:
POLICY NUMBER:
1.
Admitted Insurer:
Address:
Phone Number: Underwriter
Reason for Declination (enter code from bottom):
2.
Admitted Insurer:
Address:
Phone Number: Underwriter
Reason for Declination (enter code from bottom):
3.
Admitted Insurer:
Address:
Phone Number: Underwriter
Reason for Declination (enter code from bottom):
Reason for Declination Codes
1. Unacceptable Class of Business 5. No Market
2. Age of Building 6. No Prior Insurance
3. Declined to Quote 7. Excessive Claims
4. Doesn't Fit Underwriting Requirement 8. Other (Please Explain)
SLA AFFIRMATION: I hold a Surplus Lines license and will do the SLA filings.
Please do the SLA filings for me. (Must send this form!)
BROKER/AGENT NAME SIGNATURE DATE
EVIDENCE OF GOOD FAITH EFFORT TO PLACE
The Surplus Line Association of Utah
This form is to be used to document the efforts made by the suplus lines broker (and/or producing agent) to place
insurance coverage concerned with an admitted insurer before approaching the suplus lines insurer.
Policy No. Name of Insured:
List the admitted insurers contacted.
NAME OF INSURER NAME OF UNDERWRITER PHONE NUMBER
1.
Reason for Declining:
2.
Reason for Declining:
3.
Reason for Declining:
If any additional insureds were contracted, attach an additional list.
Provide any further explanation about the insured and your effort to place the insurance with an admitted insurer
which would help support the need to place the policy with a surplus lines insurer. Explain why you consider this
to be reasonable evidence of a good faith effort to place the coverage with an admitted insurer.
Attach additional sheets if necessary.
SLA AFFIRMATION: I hold a Surplus Lines license and will do the SLA filings.
Please do the SLA filings for me. (Must send this form!)
Signature of Producing Producer Signature of Surplus Lines Broker
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