This short form application is designed to allow an Allsouth Professional Liability team member to determine if we will be able to place coverage with a limited amount of information. We know your time is valuable and we won’t make you complete a full application until verifying we can place coverage and offer a competitive quote. You may also fax or email any fully completed application for the risk to Patrick Palmer at the address listed above.

How many years has the applicant been in business?

What is the applicant's total number of full time employees?

What is the applicant's premium volume?

PERSONAL LINES

Automobile – Standard  $ 

Automobile - Non-standard (including Assigned Risk, JUA’S, etc.) $

Homeowners – Standard $

Homeowners – Non-standard (including FAIR Plans) $

Personal Umbrella $

Other (describe) $

TOTAL PERSONAL LINES........ $

COMMERCIAL LINES 

Workers Compensation $

Long Haul Trucking $

Commercial Auto (including Livery) $

Commercial General Liability $

BOP (Business Owners Policy) $

Commercial Property $

Ocean/Wet Marine $

Inland Marine $

Bonds $

Aviation $

Commercial Umbrella/Excess $

Physicians & Hospitals $

Professional Liability $

Trusts including Workers Compensation Trusts, MET’S, MEWA’S, etc $

Risk Retention Plans $

Crop/Hail $

Other (Describe) $

TOTAL COMMERCIAL LINES $

LIFE/ACCIDENT/HEALTH LINES: 

Individual Life $

Group Life $

Individual Health $

Group Health $

Accident $

TOTAL LIFE/ACCIDENT/HEALTH LINES $

Does the applicant currently have errors and omissions coverage in place?

Yes No

What is the name of the applicant's current carrier?

What is the applicant's renewal date?

What are the applicant's current limits of liability?

Has the applicant had any reported claims in the past 3 years?

Yes No

If you answered yes to the question above please provide a brief description of the claims an estimate of the total claims paid.

Are there any known situations that could give rise to future claims?

Yes No

If you answered yes to the question above please provide a brief description of the situation or situations that could give rise to a claim or claims.

Please fill out your contact information below so that an Agency Marketing representative can contact you personally to discuss your risk's application.

Name of Agency:

Agent's Name:

Agent's Email:

Agent's Telephone:

Agent's Fax:

Agent's Address:

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