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IAP Renewal Questionnaire

Step 1 of 6

16%

Coverage Eligibility

Has the Applicant done ANY of the following within the last 6 years?(Required)

Placed coverage or been involved in any Reinsurance business;

Placed coverage for a company directly involved in the growth, sale or distribution of any product related to the Marijuana industry;

Performed any activities as a Managing General Agent/Program Administrator, or in any similar capacity, for an insurance company;

Performed any claims handling or had any claims settlement authority;

Performed third party administrator duties;

Placed any Medical Malpractice, Energy, Aviation, Animal Husbandry, Contingency, Crop, Long‐Haul Trucking, or Personal Accident insurance coverage; and

Performed any Financial Planning activities which in any given year collectively exceeds 10% of the Applicant’s annual revenue for that given year

NONE OF THE ABOVE

Did you place these coverages through a wholesaler who specializes in these placements?(Required)

Yes

Please select ALL of the following procedures you implement in your office:(Required)

Has and/or provides checklists and written protocols to staff as to what is required for placement/renewal of coverage;

Requires that all communication be documented, written instructions obtained, and that the documentation be preserved;

Uses a diary/calendar system to keep track of deadlines and/or significant dates in order to timely follow up with clients;

Has procedures in place for verification of payees, including telephone verification, and email/wire address comparisons;

Provides or requires additional training to its staff in addition to basic licensing requirements; and

Requires written confirmation from their client if placing business with insurers with an AM Best rating of B+ or less.

Applicant Information

Name of Applicant (include all dba’s):(Required)

Has there been a change in mailing/physical address for the agency in the last year?(Required)

Yes

New Address:(Required)

Street Address City State ZIP Code

Name of person filling out this form:(Required)

First Last

Contact Email:(Required)

Contact Phone:(Required)

Estimated gross revenue for the current 12 months:(Required)

For clarity: This is the estimated gross commissions and agency fees you are expecting to receive over the next 12 months, NOT the total written premium your agency is expected to write.

Do you currently have a Cyber Liability insurance policy in force?(Required)

Yes

Cancellation

Have you had any agency contracts cancelled by an insurance carrier for reasons OTHER THAN lack of production?(Required)

Yes