Affinity Insurance Agency, Inc.
Insurance Agents Professional Liability Form
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101 		Tel. 770-974-5502
Fax 770-974-5359
Just give us a few facts about your firm and we can provide you with a premium estimate. We will need to see a fully completed application before we can send you a firm quote, but this should be enough information for a reasonably good estimate.
1.-Contact Person:
Firm:
Phone:
Email: 		Address:
City: State: Zip: Fax:
County:
Website:
Consent Form: By entering my firm name, fax number (s), and my name above, I am authorized to and consent to the firm receiving faxes sent by or on behalf of Affinity Insurance Agency, Inc.
2.-Number of Employees: # Locations: Date firm Founded:
3.-Please give your annual premium volume, commissions & fees:
Year
Premium Volume
Commission & Fees
4.- Please list the percentage of business placed as Retail:
Agent/Broker % Wholesaler %
MGA, GA, Program Administrator % Other (Specify)  %
5.- What is the percentage of your total premium volume from the following.
(Total must equal 100%)
Commercial Lines  
Commercial Auto %
Long Haul Trucking %
Commercial Multi-Peril %
GL/Products %
Commercial Marine %
Workers Comp. %
Crop Hail %
Inland Marine %
Professional Liability/D&O %
Aviation %
Other %
 Personal Lines  
Standard Auto %
Non-Standard Auto %
Homeowners/Umbrella/Marine %
Other %
Life, Accident & Health  
Individual Life %
Individual A&H %
Group Life %
Group A&H %
Other %
Total must equal 100%
6.-Please list the top three insurers where you have placed business in the past two years. Please give names of Insurance Companies, not General Agents or Wholesalers.
Insurer
Annual Premium Volume
Years Represented
6A.-What percentage of your business is with insurance companies rated B+ by AM Best or less? %
7.- Have you had or reported any E&O claims within the last five (5) years? Yes No
Does anyone applying for coverage have knowledge of any potential E&O claims? Yes No
Have you or anyone applying for coverage ever been the subject of a disciplinary action or investigation or complaint as a result of any professional activities? Yes No

If "yes" to any of the above, please attach an explanation including dates, amount paid and reserved and what you did to avoid similar problems.
 
Please provide an explanation:

8.-Current Malpractice Insurer:
Retroactive Date of Policy:
Current Deductible:
Deductible Desired:

Expiration Date of Policy:
Current Limits of Liability:
Limits of Liability Desired:
Current Premium:

9.- Do you have claim draft authority?: Yes No
If so, for what lines and companies and how much authority? (attach details)
Add your Comments:
10.-Do you provide any Third Party Administration services? Yes No
If yes, please add a description of your services.
Add your Comments:


3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
September 2007