Post on 06-Jul-2020
1
RLI TRANSPORTATION A Division of RLI Insurance Company
2970 Clairmont Road, Suite 1000
Atlanta, GA 30329
Phone: 404-315-9515 Fax: 404-315-6558
AGENCY/BROKER PROFILE Please type your answers. Use a separate answer sheet if necessary.
A. GENERAL INFORMATION
1. NAME OF FIRM:___________________________________________________________________________
2. PRINCIPAL ADDRESS:_____________________________________________________________________
(STREET) (CITY) (STATE) (ZIP)
3. MAILING ADDRESS:_______________________________________________________________________
(STREET) (CITY) (STATE) (ZIP)
4. PHONE:______________ FAX:_____________ 800:_____________ E-MAIL ADDRESS:______________
5. TYPE OF ENTITY: [ ]CORPORATION [ ]PARTNERSHIP [ ]INDIVIDUAL
6. FEDERAL ID NUMBER:_______________
B. BACKGROUND
1. YEAR BUSINESS ESTABLISHED:_______________
2. DURING THE PAST FIVE YEARS HAS THE FIRM ACQUIRED/MERGED WITH ANOTHER FIRM OR
HAS THE FIRM CHANGED NAMES? [ ]YES [ ]NO
IF YES, PLEASE DESCRIBE:________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. IS FIRM ENGAGED IN, OWNED BY, ASSOCIATED OR AFFILIATED WITH, OR CONTROLLED BY
ANY OTHER BUSINESS INTEREST? [ ]YES [ ]NO
IF YES, PLEASE EXPLAIN:_________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. ARE YOU A MEMBER OF: [ ]ATA [ ]MCA [ ]OTHER
IF OTHER, PLEASE LIST:___________________________________________________________________
C. PRINCIPALS AND PERSONNEL
1. BREAKDOWN OF PRODUCER’S STAFF (Number): Current Year Prior Year
PRINCIPALS, PARTNERS, OWNERS: ____________ ____________
OFFICERS, MANAGERS: ____________ ____________
BROKERS (Other than above): ____________ ____________
UNDERWRITERS: ____________ ____________
OTHER EMPLOYEES: ____________ ____________
TOTAL STAFF: ____________ ____________
2
2. PRINCIPALS, OFFICERS, BROKERS – LIST IN ORDER OF PERCENTAGE OF OWNERSHIP:
TITLE YEAR YEAR
OR STARTED IN STARTED WITH PERCENT
NAME POSITION INSURANCE PRODUCER OWNERSHIP
_______________________ ____________ ___________ ___________ ___________
_______________________ ____________ ___________ ___________ ___________
_______________________ ____________ ___________ ___________ ___________
_______________________ ____________ ___________ ___________ ___________
_______________________ ____________ ___________ ___________ ___________
D. OPERATIONS
1. DOES YOUR FIRM OPERATE AS A WHOLESALER, MGA, RETAILER OR COMBINATION?
______% RETAIL ______% WHOLESALE BROKERAGE ______% MGA BINDING AUTHORITY
2. HOW IS YOUR ORGAINZATION LICENSED, I.E., EXCESS AND SURPLUS LINES BROKER,
REINSURANCE INTERMEDIARY, OR OTHER INSURANCE/REINSURANCE ORGANIZATION?
__________________________________________________________________________________________
__________________________________________________________________________________________
3. LIST STATES WITH LICENSES:
In-Force # Brokers In-Force # Brokers In-Force # Brokers
Business Placing Business Placing Business Placing State License # (Yes / No) Business State License # (Yes / No) Business State License # (Yes / No) Business
AL KY ND
AK LA OH
AZ ME OK
AR MD OR
CA MA PA
CO MI RI
CT MN SC
DE MS SD
DC MO TN
FL MT TX
GA NE UT
HI NV VT
ID NH VA
IL NJ WA
IN NM WV
IA NY WI
KS NC WY
4. IF YOU ARE AN MGA, DO THE RETAIL AGENTS/BROKERS FOR WHOM YOU PLACE BUSINESS
SIGN A CONTRACT REGARDING SUBMISSION OF BUSINESS AND PAYMENT OF PREMIUM?
[ ]YES [ ]NO IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT.
3
E. PREMIUM VOLUME AND DISTRIBUTION
1. YOUR TOTAL VOLUME OF BUSINESS: PRIOR CURRENT NEXT YEAR
COMMERCIAL AUTO (Liability)
Large Fleet Truck (26+ power units) ____________ ____________ ____________
Small Fleet Truck (1-25 power units) ____________ ____________ ____________
Public Auto ____________ ____________ ____________
COMMERCIAL AUTO (Physical Damage)
Large Fleet Truck (26+ power units) ____________ ____________ ____________
Small Fleet Truck (1-25 power units) ____________ ____________ ____________
Public Auto ____________ ____________ ____________
CARGO ____________ ____________ ____________
GENERAL LIABILITY ____________ ____________ ____________
EXCESS & UMBRELLA ____________ ____________ ____________
WORK COMP & OCC ACC ____________ ____________ ____________
PROPERTY ____________ ____________ ____________
OTHER ____________ ____________ ____________
Please Describe:____________________________________________________________________________
2. LIST MAJOR COMPANIES IN ORDER OF PREMIUM VOLUME:
BINDING
YEARS ANNUAL LOSS AUTHORITY NUMBER
NAME REPRESENTED VOLUME RATIO (YES / NO) YEARS
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
______________________ ______________ __________ ______ ____________ _________
3. DESCRIBE SCOPE OF BINDING AUTHORITY. I.E.: LIMIT OF AUTHORITY, LINES, ETC.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. COMPANIES DISCONTINUED IN THE LAST FIVE YEARS:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4
5. DO YOU ADJUST CLAIMS FOR ANY COMPANIES YOU REPRESENT? [ ]YES [ ]NO
IF YES, PLEASE EXPLAIN:_________________________________________________________________
_________________________________________________________________________________________
6. DESCRIBE ANY SAFETY OR LOSS CONTROL SERVICES PROVIDED BY YOUR ENTITY:
__________________________________________________________________________________________
__________________________________________________________________________________________
F. PRODUCTION TO COMPANY
ANTICIPATED VOLUME TO COMPANY WILL COME FROM THE FOLLOWING SOURCES:
LF TRUCK SF TRUCK PUBLIC AUTO
(26+ Units) (1-25 Units)
1. NEW BUSINESS ___________ ___________ ______________
2. TRANSFER FROM CURRENT COMPANY ___________ ___________ ______________
3. TRANSFER FROM DISCONTINUED COMPANY ___________ ___________ ______________
4. TOTAL (1+2+3) ___________ ___________ ______________
COMMENTS:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
G. FINANCIAL INFORMATION
IF NOT HANDLED BY MAIN OFFICE, PROVIDE ADDRESS:
1. ADDRESS:_____________________________________________________________________
(STREET) (CITY) (STATE) (ZIP)
2. PHONE:______________ FAX:_____________ 800:_____________ E-MAIL ADDRESS:______________
3. NAME OF ACCOUNTING CONTACT:________________________________________________________
4. BANK REFERENCE:_______________________________________________________________________
NAME:___________________________________________________________________________________
TRUST ACCOUNT #:_______________________________________________ OTHER:________________
BANK ADDRESS:__________________________________________________________________________
BANK CONTACT:__________________________________________________ PHONE:_______________
ATTACH COPY OF LATEST FINANCIAL STATEMENT.
5. DO YOU MAINTAIN FIDELITY COVERAGE? ARE OFFICERS COVERED?
[ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING:
INSURANCE COMPANY:___________________________________________________________________
POLICY LIMITS:___________________________________________________________________________
POLICY DEDUCTIBLE:_____________________________________________________________________
EXPIRATION DATE:_______________________________________________________________________
5
6. DO YOU MAINTAIN E & O COVERAGE? [ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING:
INSURANCE COMPANY:___________________________________________________________________
POLICY LIMITS:___________________________________________________________________________
POLICY DEDUCTIBLE:_____________________________________________________________________
EXPIRATION DATE:_______________________________________________________________________
7. HAS ANY MEMBER OF YOUR FIRM RECEIVED ANY DISCIPLINARY ACTION BY A STATE
INSURANCE DEPARTMENT OR OTHER REGULATORY AUTHORITY? [ ]YES [ ]NO
IF YES, EXPLAIN:_________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
8. IS THERE ANY PENDING OR THREATENED LITIGATION OR JUDGEMENTS WITHIN THE PAST
FIVE YEARS EXCEEDING $10,000 AGAINST THE BROKER OR ANY OF THE PRINCIPALS?
[ ]YES [ ]NO IF YES, EXPLAIN:_________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
THE UNDERSIGNED HEREBY DECLARES THAT THE ANSWERS GIVEN WITH RESPECT TO THE
FOREGOING QUESTIONS ARE TRUE, COMPLETE AND ACCURATE WITH NO
MISREPRESENTATIONS, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT.
SIGNATURE OF APPLICANT:__________________________________
TITLE OF APPLICANT:________________________________________
DATE OF SIGNATURE:________________________________________
***** BE SURE TO INCLUDE COPIES OF THE FOLLOWING DOCUMENTS:
1. LICENSES 2. FINANCIALS – P&L AND BALANCE SHEET 3. E & O DEC PAGE
RETURN TO:
ATTENTION: LICENSING
RLI TRANSPORTATION
2970 CLAIRMONT ROAD, SUITE 1000
ATLANTA, GA 30329