Commonwealth Insurance Advantage

Primary Contact First Name*

Primary Contact Last Name*

Primary Contact Title*

Primary Contact Work Phone*

Primary Contact Cell Phone*

Primary Contact Email*

Company Name*

Please provide the full name of the applicant (Including all subsidiaries and related entities for which coverage is requested).

DBA

If any.

Address Line 1*

Physical address.

Address Line 2

Mailing address.

City*

State / Province*

ZIP / Postal Code*

Fax #

Website*

Do you have more than one location?*

Yes

No

Please provide same information for the other locations here.

Date Business Established*

If in operation for less than three years, please attach license(s) and resume(s) for all principles...

Form of Organization*

If other, please advise what other organization type...

Is the applicant firm controlled, owned (in whole or part), affiliated or associated with any other firm, corporation, or entity?

Yes

No

If "yes" to the previous question, please provide the entity's name, percent (%) ownership interest, and the relationship to the applicant.

During the past five years, has the name of the firm been changed, or has any business/firm been acquired, merged into, consolidated or sold by/from the original firm?*

Yes

No

If "yes" to the previous question, please explain and provide name(s) of the predecessor firm(s).

Has there been a change in management structure, including any additions, or deletions of any principle owners, managers, or brokers?*

Yes

No

If "yes" to the last question, please explain...

Please describe the specific lines of business you specialize or focus on?*

Please list the top five insurance companies for whom you produce premium. Please be sure to include the company name, how many years represented, annual premium, and their current A.M. Best rating.

Have you ever placed coverage or been involved in Self-Insured Captives, Risk Retention Groups, Risk Purchasing Groups, or Multiple Employer Trust?*

Yes

No

If you answered "yes" to the previous question, please provide an explanation including the names of the programs, carriers, extent of coverage, provided administrative duties, and any financial information.

In a normal year, how often do you interact each of your insured clients?*

1

2-5

6-10

10+

What is your client's preferred method of communication?*

Work Phone

Cell Phone

Email

WhatApp

Personal Visits

What is your preferred method of communication?*

Work Phone

Cell Phone

Email

Text

Please indicate the percentage placed with carriers via other brokers, MGA's, Reinsurance Intermediary, Surplus LInes Broker, or Wholesalers?*

Please provide a summary of your total premium written within each of the following lines of business: CMP/Package, CGL/BOP, Umbrella/Excess, WC, Professional Liability, Products Liability, and Other.*

Please provide a summary of your total premium written within each of the following healthcare niches: Skilled Nursing Facility, Assisted Living Facility, Home Healthcare, and/or Other. *

Please list the top five States you write business in.*

Please provide an employee breakdown of your organization. Please advise how many of the following: Owners/Officers/Partners, Solicitors/Brokers/Agents, Employees at Agency, Employees specializing in Healthcare, and all other.*

Does your agency employee independent contractor producers?*

Yes

No

If you answered "yes" to the last question, do you require your independent contractors to provide their own professional liability insurance?

Yes

No

What is the retroactive date of your current professional liability policy?*

What is your agency license number?*

What is your broker license number?*

Please provide the name of the individual whom will need to sign this appointment contract.*

Please provide the name of the individual whom will need to sign this appointment contract.

What is the signer's title?

Please attach the following documents: Agency License, Broker License, Agency E&O Declarations Page, and Agency Cyber Liability Page.

Signature Block

This only has to be signed by the individual providing the answers to this form.

Signature Block

I/We declare that I/we have reviewed this Profile for accuracy before signing it, the above statements and representations are true and correct, and that no facts have been suppressed or misstated. I/we understand that this is a Profile for insurance purposes only and that the completion and submission of this Profile does not bind the Company to sell nor the Applicant to purchase this insurance. I/we nevertheless acknowledge that any contract of insurance issued by the Company in response to this Profile will be in full reliance upon the statements and representations made in this Profile and that this Profile will be made part of the policy. I/we understand that any contract or insurance issued by the Company in response to this Profile will be issued on a claims-made form. Any persons who knowingly and with intent to defraud any insurance company or other person, files a Profile for insurance, or statement of claim containing any materially false information or conceals for the purposes of misleading, information concerning any material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty. I/we hereby declare that the above statements and particulars are true, and I/we agree that this Profile shall be the basis for any contract of insurance issued by the Company in response to it.

Lastly, by signing this document, the broker/agent represents that it is an insurance broker/agent in good standing, licensed by the regulating authorities in each State in which it conducts business. Failure to maintain a license in good standing in each State in which it conducts business during the effective dates of this Agreement shall be considered a material breach of this agreement.

New Broker Profile

Signature Block