SUPPLEMENT FOR INSURANCE RELATED SERVICES
All questions MUST be completed in full. 
If space is insufficient to answer any question fully, attach a separate sheet.  
1.	Full name of Applicant:  	

2.	Line(s) of Business on which the Applicant provides their services:  
	Percentage
(a)	Life	[   ] Yes   [   ] No		%
(b)	Accident /Health 	[   ] Yes   [   ] No		%
(c)	Pension	[   ] Yes   [   ] No		%
(d)	Other Benefits: (specify)		 	[   ] Yes   [   ] No		%
(e)	Personal Property Home or Auto	[   ] Yes   [   ] No		%
(f)	Personal Liability Home or Auto	[   ] Yes   [   ] No		%
(g)	Commercial Property	[   ] Yes   [   ] No		%
(h)	Workers’ Compensation	[   ] Yes   [   ] No		%
(i)	General Liability	[   ] Yes   [   ] No		%
(j)	Structured Settlements	[   ] Yes   [   ] No		%
(k)	Other (specify)  				%
		TOTAL	100%

3.	Provide the percentage of the Applicant’s clients in the following categories:
	Percentage
(a)	Insurers		%
(b)	Insureds		%
(c)	Self Insureds		%
(d)	Other (specify)  			%
		TOTAL	100%

4.	List the Insurers and/or Risk Bearing Entities for which the Applicant provides professional services to account for 85% of the Applicant’s gross revenues.
	Insurer or Risk Bearing Entity	Best’s Rating (If applicable)

					

5.	Does the Applicant adjust claims?	[   ] Yes   [   ] No	
	If Yes, answer the following.
(a)	Does the Applicant have authority to deny coverage for claims?	[   ] Yes   [   ] No
(b)	Largest Single Loss Adjusted in the past 36 months in dollar amount of settlement:	$	
(c)	Average Size of Loss Adjusted in the past 36 months in dollar amount of settlement:	$	

6.	Does the Applicant close structured settlements?	[   ] Yes   [   ] No
	If Yes, answer the following.
(a)	Does the Applicant fully disclose the cost of the structured settlements to all parties involved in
	the settlement?	[   ] Yes   [   ] No
(b)	Provide a sample settlement closing statement.

7.	Attach copies of all current insurance related licenses of the Applicant and its employees.
Signing this Supplement does not bind the Company to provide or the Applicant to purchase the insurance.
It is understood that information submitted herein becomes a part of the application for insurance and is subject to the same declarations, representations and conditions.
Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date. 
			
Name of Applicant		Title
			
Signature of Applicant		Date