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LIMIT, EFFECTIVE, BILLING, 4 QUESTIONS, ADDITIONAL COMMENTS & APPLICATION METHOD
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LIMIT, EFFECTIVE, BILLING, 4 QUESTIONS, ADDITIONAL COMMENTS & APPLICATION METHOD

SELECT LIMIT TO BIND
Please select limit and premium to bind next to appropriate limit. Limits to $5,000,000 are shown.

ENTER EFFECTIVE DATE

  • Enter the effective date of the policy.
  • Policies Can NOT be backdated.
  • All policies will be issued for one-year terms. If you wish to amend to shorter term, please advise in ADDITIONAL COMMENTS.

    BILLING METHOD
    Please select if we are to Direct-bill or Agency-bill the policy:
    Direct.  We will send both you and the insured the same invoice for the Gross Premium and Policy Fee. Your commission will be paid on a quarterly basis.
    Agency.  We will bill you for the net premium + policy fee.
    All premiums must be received within 15 days of the effective date for new policies.
    Renewal policies will be billed direct. They must be received prior to effective date.
    Your commission will be paid on a quarterly basis.

    4 QUESTIONS
    You must be able to answer true to the following 4 questions. If any are false you must submit the applicants to us for approval.

    None of the applicants applying for this insurance are the following:

  • A professional entertainer, a current or former elected public official, notorious for the flamboyance of life style, appear regularly on TV or in magazines or in newspapers, nationally or regionally known for controversial activities or politics, or a Division 1 college athlete or coach who appear regularly on TV.
  • None of the applicants applying for this insurance have had four (4) or more losses or total losses over $25,000 within the past three years, or currently has an open claim.
  • None of the driver(s) listed in my application has had a Major Traffic Violation in the last 5 years.
  • All primary policies to be listed are:
    1. Rated "B+ (VII)" or higher by A.M.Best corporation
    2. Admitted and licensed to insure in the state where exposure is located? (No Nonadmitted carriers including Lloyds may be used unless approved by special acceptance.)

    ADDITIONAL COMMENTS If you have any specific comments you wish to relay to the underwriters with your order, please feel free to do so here.

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