APPLICATION FOR "CLAIMS MADE" AND REPORTED INSURANCE POLICY FOR LIFE INSURANCE BROKERAGE/AGENCY PROFESSIONAL LIABILITY (E&O)
In order to avoid delays, ALL questions must be answered.














*If less than 3 years, attach resume of principle
(.xls or .xlsx, .doc or .docx, max 2.5 MB.)






















Total Brokerage/Agency Revenue written for all agents, representatives, and services provided:



$
$
$

%
provide copy of MGA contract
(.xls or .xlsx, .doc or .docx, max 2.5 MB.)


%
%


Full-Time * Part-Time Average Years of Insurance Experience Average Turnover Rate %








Name Professional Designation No. of Years
with Applicant
Provinces Licensed In Name of current
E&O carrier
attach list if additional space is required
(.xls or .xlsx, .doc or .docx, max 2.5 MB.)





Activity Performed? Approximate Percentage
of Total Gross Revenue
Coverage Desired?
Yes No Yes No
%
%
%
%
%
%
%
%
%
%













Office Procedures for all locations








































$
$
$



Requested Limit of Liability:






PRIVACY NOTICE TO APPLICANT

The undersigned applicant authorizes Westport Insurance Corporation (WIC); (a) to collect his/her personal information in order to process and evaluate this application, to provide insurance if coverage is accepted, to obtain reinsurance for the policy, to investigate any claim made under the policy, which may require third parties to collect insured's personal information, and to serve other purposes as permitted by applicable law; (b) to disclose his/her personal information to its subsidiaries, affiliates, reinsurers and agents for these purposes, and (c) to use his/her personal information for these purposes. Furthermore, the undersigned authorizes any third party who receives undersigned's personal information from Westport Insurance Corporation to collect, use and further disclose the personal information for these purposes.

NOTICE TO APPLICANT

Applicant hereby warrants and represents that the statements and answers to questions made above and attachments hereto are true and applicant has not omitted or misrepresented any information. I understand and accept that the policy applied for provides coverage on a “claims made and reported” basis for only those claims that are made against the insured while the policy is in force and that coverage ceases with the termination of the policy. All claims will be excluded that result from any acts, circumstances or situations known prior to the inception of coverage being applied for, that could reasonably be expected to result in a claim.

Applicant understands and agrees that the completion of this application does not bind WIC to issuance of any insurance policy. Further, the applicant understands and agrees that she or he is obligated to report any changes in information provided in this application that occur after the date of the application.

For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Westport Insurance Corporation’s insurance business in Canada.

THE APPLICATION MUST BE SIGNED AND DATED BY THE APPLICANT.

The applicant understands and agrees that she or he is obligated to report any changes in the information provided in this application which occur after the date of the application.