Mercator Risk Services
99 Pratt Street - Suite 200
Hartford, CT 06103
Tel: (860) 527-9717 Fax: (860) 527-2438
E-Mail: Hinfo@mercatorpro.com
Web: Hmercatorpro.com
ERRORS AND OMISSIONS INSURANCE APPLICATION
SPECIALTY INSURANCE BROKERS E&O PROGRAM
Notice:
This is an Application for a "Claims Made" Policy.
The Policy issued by the insurers (the "Companies") provides that the Limit of Liability available to pay judgments or
settlements shall be reduced by amounts incurred for claims expenses. Further note that amounts incurred for claims
expenses shall be applied against the deductible or retention amounts.
To the Applicant or submitting broker:
If written, this risk will be written on a surplus lines basis. Certain filings and tax payments may be required to comply
with the insurance regulations of the state in which the risk is located. The Applicant or submitting broker is responsible
for satisfying these requirements or designating a licensed surplus lines broker who will. Please indicate your agreement
by completing and signing the attached Surplus Lines Compliance Supplement and returning it with this Application.
Instructions to the Applicant:
1.
Answer all questions. If the answer to any question is none, state "None".
2.
If space is insufficient to answer any question fully, attach a separate sheet.
3.
The Application must be signed and dated by an authorized representative of the Applicant who is an officer of
the Applicant.
4.
Additional applications must be completed or a description attached for any proposed additional insureds, and
must include a description of the relationship with the Applicant. Independent Contractors are not covered unless
specifically noted in the Application as proposed additional insureds.
5.
Please use attached supplemental forms to provide additional information where applicable.
All inquiries and communications should be addressed to Mercator Risk Services Inc.
ERRORS AND OMISSIONS INSURANCE APPLICATION
SPECIALTY INSURANCE BROKERS E&O PROGRAM
Contact:
Current Date:
1. Applicant:
2. Address:
3. Telephone:
Fax:
4. Address of all other office locations or branches:
Web Site:
5. Year Established:
6. Applicant is: … Corporation … Partnership … Individual … Other
7. Names of all Shareholders and percentages owned:
8. Names of subsidiary operations and percentages owned:
9. During the past five years has the name of the Applicant been changed, has any operation or entity been
discontinued, or has any other business been purchased, merged or consolidated with the Applicant:
Yes …No If yes, provide full details:
10.
11.
12.
13.
Does the Applicant operate outside the U.S.A.:
Is the Applicant engaged in, owned by, associated with or controlled by any other business:
Does the Applicant own, manage or control any other business:
Does the Applicant own, manage or control any insurance company or captive:
If yes to any of these questions, provide details:
Yes
Yes
Yes
Yes
No
No
No
No
14. Provide the Applicant's actual or estimated annual premium volume and income figures for the years noted:
Fiscal
Year
Premium
Volume
Commissions
& Fees
Other Income
(Describe)
Total
Revenues
Net
Income
Next
Current
Previous
Previous
Previous
________
________
________
________
________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
_________
_________
_________
_________
_________
____________
____________
____________
____________
____________
Dates of Fiscal Year
-
From:
15. Number of total active staff of each type (including part-time):
(a) Partners, directors, and officers:
(b) Brokers and Underwriters, excluding above:
(c) Independent Contractors:
(d) Other employees:
Total Employees:
To:
16. Does the Applicant engage in any of the following activities: If yes, provide total annual revenues:
Current
Annual
Revenues
Insurance Agent/Broker
Managing General Agent/General Agent
Excess and/or Surplus Lines Broker
Risk Manager/Risk Management Consulting
Program Administrator
Consultant
Third Party Administrator
Ins. or Reinsurance Company Management
Reinsurance Intermediary
Inspection and/or Engineering Services
Real Estate Services
Investigation Services
Claim Adjustment
Actuarial Services/Consulting
Other - Please Describe
$
$
$
$
$
$
$
$
$
$
$
$
$
Next Years
Estimated
Revenues
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
17. What percent of the Applicant's annual premium volume is classified as:
a.
b.
c.
d.
Retail:
%
Admitted:
%
%
Personal:
Standard Property/Casualty:
Wet Marine:
Professional Liability:
Long Haul Trucking
Life, Group, A&H:
Mutual Funds:
Explain “Other”:
Wholesale:
Non-admitted (E&S):
Commercial:
%
%
%
%
%
%
%
%
%
Bonds:
Aviation:
Reinsurance:
Crop/Hail
Annuities
Other:
%
%
%
%
%
%
18. Describe your specialty(ies) and the functions you perform in this area. Please provide marketing literature
which describes your organization.
19. List all insurance or reinsurance markets in which business has been placed in the last 5 years and the percentage of
your premium. Specify whether an agency or broker relationship exists with each market, and whether you have
underwriting authority. Use the Insurance Markets Supplement if space is insufficient.
20. Do you delegate any binding or underwriting authority to any sub-producers or other entities? …Yes …No
If yes, provide details:
21. List all contracts during the last five years providing claims settlement authority in excess of $10,000. Include
the carrier, the line of business, the maximum amount of the authority, the average number of claims reported
annually, and the dates held:
22. In each situation in which the Applicant has authority to adjust or settle claims, what are the Applicant's procedures
in the event of a denial of a claim or a denial of coverage?
23. Does the Applicant design or administer self-insurance programs, manage captives, risk retention groups or
other insurance companies, or provide risk management services: …Yes …No If yes, explain:
24. Does the Applicant segregate fiduciary funds (premiums, etc.) in a dedicated bank account separate from operating
funds: …Yes …No If no, provide details on the handling of fiduciary funds:
25. Office Procedures:
Are only written binders used: (ie: no verbal binders)
Are copies of all binders mailed or faxed to the producer:
Does Applicant require a signed brokerage agreement:
YES
NO
26. Do you have a web site: …Yes …No If yes, Web Site Address(s):
Describe the functions the web site performs:
27. Describe any transactional functions on the web site:
28. What additional functions do you plan to add to your website in the next two years:
29. Do you now, or do you plan on, transacting insurance over the internet: …Yes …No
If yes, please provide details including estimated premium volume:
30. Do you have a privacy statement, standard representations or disclaimers on your site: …Yes …No
31. Do you use email for quoting, accepting, binding or adjusting coverage: …Yes …No
If yes:
a. provide details on secure record retention procedures:
b. how do you ensure receipt by the receiving party:
32. What are your backup procedures for your agency management and accounting systems:
33.
a. List all Errors and Omissions insurance carried during the past five years.
Inception
Date
Mo/Day/Yr
Expir.
Date
Mo/Day/Yr
Insurance
Company
Limits of
Liability
Deduct.
Premium
Claims
Made
Y/N
b. If the expiring insurance is written on a "claims-made" basis, give the retroactive date of the expiring insurance. (If
none, state "None.") _ _________
c. If insurance has expired or was non-renewed, was an extended reporting period purchased? …Yes …No
If yes, provide period:
34. Has any Application for similar insurance on behalf of the Applicant, any partner, officer, director or employee of
the Applicant, or any of its predecessors in business been declined or cancelled, renewal of such insurance refused,
or any special terms imposed: …Yes …No If yes, provide full details:
35. Has the Applicant, any person proposed for this insurance or any employee of the Applicant ever had any insurance
license revoked or suspended, or been fined or disciplined in any way, by any governmental licensing agency or
other regulatory body: …Yes …No
If yes, explain:
36. Have any claims or suits been made against the Applicant or any of its predecessors in business, or any of the past or
present partners, directors, officers, brokers or employees: …Yes …No If yes, complete the Claim Information
Supplement (attached), giving details and the status of each and every claim.
37. Is the Applicant, after inquiry of each person proposed for insurance, aware of any circumstance, error, omission or
offense which may result in a claim being made against the Applicant or any of its predecessors in business, or any
of the past or present partners, directors, officers, brokers or employees: …Yes …No If yes, explain using the
Claim Information Supplement (attached).
It is agreed that if such knowledge or information exists, any claim or action arising therefrom is excluded from the
proposed coverage.
NOTE for Applicants who are applying for renewal of an existing policy issued by the Companies: Claim and incident
reporting, as required under the Companies' policy, must be made separately from and in addition to the Claim
Information Supplement required for this Application.
NOTE: Attach financial statements (income statement and balance sheet, audited if available) for the past three years.
If fiscal year-end financials less than six months old are not available, please provide interim financials in addition.
Insurance requested:
Limit:
Deductible:
Proposed Named Insured:
Proposed Additional Insureds:
Effective Date:
I/We, the Applicant, hereby declare that the particulars and statements in this Application and accompanying exhibits are
true and that I/we have not omitted or suppressed or misstated any material fact and that at the present time, I/we have no
reason to anticipate any claim being brought against me/us for any act, error of, or omission on, the part of me/us or any
proposed insured, except as detailed in this Application, and agree that this Application and accompanying exhibits shall
be the basis of any policy of insurance which may be issued by the Companies and shall be deemed a part thereof.
I/We accept notice that any policy which may be issued will apply on a "Claims-Made" basis and that the deductible
amounts will apply to loss payment and (whether or not loss payment is made) to claims expenses. I/We hereby further
acknowledge that I/We are aware that claim expenses that are incurred shall be applied against the deductible amounts.
I/We acknowledge that losses and claims expenses paid by the Companies and falling within the deductible amounts will
be immediately reimbursed by me/us, should a policy be issued.
I/We hereby acknowledge that I/we are aware that the limits of liability contained in the policy shall be reduced, and
may be completely exhausted, by claims expenses and, in such event, the Companies shall not be liable for claims
expenses or the amount of any judgment or settlement to the extent that such exceeds the limits of liability of the policy.
It is also agreed that notice of a claim or incident in a Claim Information Supplement or other form attached to this
Application for renewal is not notice of claim, as required under the Companies' policy. Any such notice of claim must
be made separately from and in addition to this Application for renewal. It is agreed that claims made, incidents
reported, or incidents which I/we are aware of, prior to the inception of the proposed coverage, are excluded from this
proposed coverage.
THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANIES TO COMPLETE THE
INSURANCE, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A
POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. THE
APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED IN THIS APPLICATION CHANGES BETWEEN
THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL
IMMEDIATELY NOTIFY THE COMPANIES OF SUCH CHANGE.
I/We also hereby authorize the Companies, by signing this Application, to contact third parties and obtain any details of
prior losses or any other information which the Companies deem important.
_________________________________________
Applicant
____________________________________
Authorized Representative
_________________________________________
Date
____________________________________
Title
MERCATOR RISK SERVICES
SPECIALTY INSURANCE BROKERS E&O PROGRAM
ERRORS AND OMISSIONS INSURANCE APPLICATION SUPPLEMENT
Claim Information
Complete one form for each claim or incident. If space is insufficient to answer any question completely, attach a
separate sheet.
Full name of claimant(s):
Alleged act, error or omission upon which claimant bases claim:
Description of events leading to claim, including date of alleged act, error or omission:
Indicate: Claim/suit:
Reported incident:
Open:
Closed:
Additional defendants and the insurer providing the underlying coverage:
Current Status of claim:
Claim/incident reported to your Errors and Ommissions insurer:
Date reported:
Insurer:
Deductible:
Limit:
Yes
No
Effective Date:
Has coverage for the claim/incident been denied by any Errors & Omission insurer: …Yes
If yes, why:
Claimant's total settlement demand:
$
Insurer's Reserves/Loss Payments:
Loss Amounts:
Defense & claims expenses:
Total Reserved/Paid:
Reserved
No
Paid
I/We understand information submitted herein becomes a part of my/our Errors and Omissions Insurance Application
and is subject to the same conditions.
Applicant
Authorized Representative
Date
Title
MERCATOR RISK SERVICES
SPECIALTY INSURANCE BROKERS E&O PROGRAM
ERRORS AND OMISSIONS INSURANCE APPLICATION SUPPLEMENT
Insurance Markets
List all insurance companies in which business is or has been placed by the Applicant in the last 5 years. One name may
be used for a group of companies provided premium volume and experience is compiled in that way. All information
must be complete.
Insurance
Company
/Wholesaler
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Date
First
Represented
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
Date
Ended
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
Reason
Ended
Premium
Volume
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
Authority
/Line
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
If business is written under an underwriting authority, managing general agent agreement or other similar contract,
attach an Underwriting Authorities Supplement (attached) for each authority.
I/We understand information submitted herein becomes a part of my/our Errors and Omissions Insurance Application
and is subject to the same conditions.
Applicant
Authorized Representative
Date
Title