During the past 5 years did you or any partner director, officer, partner, employee, independent contractor or subcontractor place, or over the next 12 months do you or any partner, director, officer, employee, independent contractor or subcontractor expect to place, mutual funds or any other securities? Yes No (If YES, please complete the MGA/MGU, TPA and Mutual Funds Questionnaire) Please provide the following information for business placed by or on behalf of you and sources of other income: Projected 12 Months Current 12 Months Prior 12 Months Total P&C premium volume $ $ $ Total Life and A&H premium volume: $ $ $ Total P&C commission income $ $ $ Total Life and A&H commission income: $ $ $ Other income including sources of the $ $ $ income: Total Commission & Fee Income $ $ $ Please provide the percentage of: policies written on a direct bill basis: % gross written premium placed through a service center: % policies placed with Admitted Carriers: % gross written premium placed through a state administered fund: % business written through MGAs, other brokers or intermediaries: % Please provide the following premium volume for past 12 months production: your COMMERCIAL LINES PERSONAL LINES CMP/Package $ Auto-Standard $ CGL/Package $ Auto-Non-Standard $ Umbrella/Excess $ Homeowners $ Auto-Standard $ Non-Standard Fire $ Auto-Non-Standard $ Pleasure Boats $ Long Haul Trucking $ Mobile Homes/RVs $ Workers Compensation $ Motorcycles $ Livestock Mortality $ Wind/Flood/Earthquake $ Crop/Hail $ Umbrella $ Medical Malpractice $ Other (specify): $ Professional Liability/D&O $ TOTAL PERSONAL LINES $ Wet Marine $ Inland Marine $ LIFE AND A&H INSURANCE Bonds/Surety $ Life, Individual $ Aviation $ Life, Group $ Products liability $ A&H, Individual $ Other (specify): $ A&H, Group $ TOTAL COMMERCIAL LINES $ Annuities $ HMO/PPO/DSP $
During the past 5 years did you or any partner director, officer, partner, employee, independent contractor or subcontractor place, or over the next 12 months do you or any partner, director, officer, employee, independent contractor or subcontractor expect to place, mutual funds or any other securities? Yes No (If YES, please complete the MGA/MGU, TPA and Mutual Funds Questionnaire) Please provide the following information for business placed by or on behalf of you and sources of other income: Projected 12 Months Current 12 Months Prior 12 Months Total P&C premium volume $ $ $ Total Life and A&H premium volume: $ $ $ Total P&C commission income $ $ $ Total Life and A&H commission income: $ $ $ Other income including sources of the income: $ $ $ Total Commission & Fee Income $ $ $ Please provide the percentage of: policies written on a direct bill basis: % gross written premium placed through a service center: % policies placed with Admitted Carriers: % gross written premium placed through a state administered fund: % business written through MGAs, other brokers or intermediaries: % Please provide the following premium volume for your past 12 months production: COMMERCIAL LINES PERSONAL LINES CMP/Package $ Auto-Standard $ CGL/Package $ Auto-Non-Standard $ Umbrella/Excess $ Homeowners $ Auto-Standard $ Non-Standard Fire $ Auto-Non-Standard $ Pleasure Boats $ Long Haul Trucking $ Mobile Homes/RVs $ Workers Compensation $ Motorcycles $ Livestock Mortality $ Wind/Flood/Earthquake $ Crop/Hail $ Umbrella $ Medical Malpractice $ Other (specify): $ Professional Liability/D&O $ TOTAL PERSONAL LINES $ Wet Marine $ Inland Marine $ LIFE AND A&H INSURANCE Bonds/Surety $ Life, Individual $ Aviation $ Life, Group $ Products liability $ A&H, Individual $ Other (specify): $ A&H, Group $ TOTAL COMMERCIAL LINES $ Annuities $ HMO/PPO/DSP $
HIG_Professional_Liability_InsureWare2.0_Application.docx