Ashley General Agency      2040 N Loop 336 W, Suite 200
Conroe, TX 77304
(936) 441-5959   -   Toll Free (877) 633-5959   -   Fax (936) 521-5922

INSURANCE AGENTS ERRORS & OMISSIONS APPLICATION

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:  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: 
 
Y     N
 
Y     N
 
Y     N
 
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 forwarded after submitting 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: 
 

APPLICANT CERTIFICATION

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.

By placing the initials of the applicant in the box below, the applicant acknowledges acceptance of the above, and understands that the initials carry the effect of a signature.

     
Initials    Date    Name of Applicant    Title 

 

I have read and understand the APPLICANT CERTIFICATION section above
  (please check box before submitting)