AgentPAC Insurance Application

Important Instructions for your AgentPAC Application & Coverage

Each Agent must meet the criteria contained within this application in order to be considered an insured under the policy. By signing below, Agent hereby represents that the information contained herein is true, accurate and complete and that no material facts have been suppressed or misstated. Further, Agent understands and acknowledges that:

• If Agent's enrollment is accepted, AgentPAC will have relied upon, as representations: this application.
• The misrepresentation of any material matter by the Agent will render such Agent's coverage under the Policy null and void.
• Agent's failure to report during the policy period, either any claim made against any insured, or any act or omission known to any insured that may reasonably be expected to be the basis of a claim against any insured may create a lack of coverage.

Submission of this application does not ensure coverage will be provided.

Applicant Information - Proposed Insured

First Name:*
Middle Initial:
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State: *	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:*
Phone: (xxx) xxx-xxxx*
Fax: (xxx) xxx-xxxx
Email Address:*

Past Coverage Information

UFirst Alliance ID*
Do you currently have Agent's E&O Insurance?*	yes no
Do you require retroactive coverage?*	yes no
If yes, what retroactive date do you require (mm/dd/yyyy):*
Requested policy start date (mm/dd/yyyy): *

Background Questions

The Agent (hereafter "you") must be able to respond "no" to each of the questions posed below in order to qualify for coverage. If you respond "yes" to any of the questions below please explain in the box provided. Your application will be sent to underwriting for approval.

Within the last seven (7) years, have you had a state or federally regulated license revoked, restricted, or terminated for cause?	yes no
Within the last seven (7) years, have you been a defendant or respondent to any consumer complaint or allegation that resulted in any type of adverse decision, enforcement action, adverse order, disciplinary sanction, or censure against you by any state or federal regulatory agency?	yes no
Within the last seven (7) years, have you been the subject of any investigation, inquiry, or complaint by any state or federal regulatory agency, or any other agency, alleging any violations of unethical conduct, prohibited sales practice, or breach of professional standards that resulted in any type of adverse decision, enforcement action, disciplinary sanction, or adverse order, such as a consent order, final order, or cease and desist-type order?	yes no
Do you have any regulatory or consumer-related complaints that are pending or unsettled, or are you awaiting any arbitration or civil proceeding?	yes no
Within the last seven (7) years, have you been convicted of any felony or business-related misdemeanor, or are you currently named as a defendant, respondent, or party to any such criminal or civil action?	yes no
Are you currently the subject of any investigation, inquiry, or complaint by any state or federal regulatory agency?	yes no
Within the last seven (7) years, have you been censured, fined, reprimanded, or otherwise disciplined by an accredited designation?	yes no
Within the last seven (7) years, has your business declared bankruptcy? (personal bankruptcy not applicable)	yes no
Are you aware of or involved in any fee dispute with any of your clients?	yes no
If you selected 'yes' to any of the questions above please explain below

E-Signature

Please click the check box below and the "I Agree" button to process your enrollment form.

I affirm I have answered all of the questions truthfully and correctly to the best of my knowledge. I accept the authorization to bind and I consent to the use of an electronic signature to authenticate this insurance transaction in electronic form. I understand and agree that the insurance company will rely on my electronic signature to process and effect this insurance transaction.*

* I understand that I am not obligated to enter into transactions electronically and that I have a right to conduct insurance transactions in paper format if I wish. By clicking the "I Agree" button below, I affirmatively consent to conduct this transaction in electronic form.

5-Digit Code:*