CRITICALCAREINSURANCE.COM                     Personal Profile Worksheet

Please contract me with: (Check all that apply).

Assurity     Mutual of Omaha     AIG       Colorado Bankers     Protective


Part 1: Individual and Principal of Corporation

 

Last Name:   First Name:     Middle Initial:   Male     Female
 

Aliases/Nicknames/Maiden Name (if applicable):  
 

Social Security Number:         Your Date of Birth :      

 

Drivers License Number:       Drivers License State:  

 

Email Address:    

 

Current Employer or Company Name:    

 
 

Office

Street Address:

City:

State: 		    Zip Code:  
Phone:
   

Mailing Address:

City:

State: 		    Zip Code:  
Residence

Street Address:

City:

State: 		    Zip Code:  
Phone:

 
FAX:
 
Writing Agent: Yes   No                       Company Officer: Yes   No  
 
Preferred Method of Communication: Phone     Fax     E-mail  
 

Part 2: Corporate Information (Corporate Agency)

 

Agency Name:     Tax ID Number:    

 

Corporate Address:

City:

State: 		    Zip Code:  
   

Corporate Mailing Address:

City:

State: 		    Zip Code:  

If commissions are to be assigned to a corporation, please provide the Federal Identification Number and a copy of the corporation's state license(s) and proof of E&O coverage.
Federal Identification Number:  

 

Part 3: Contracting Information Resident & Non-resident

 

Personal – Resident State                         Corporate – Resident State  
 
Personal Non-resident State(s):

                		                                          Corporate Non-resident State(s):

               

 

                        (To select multiple states, hold down the CTRL key on a PC, or the Apple key on a Macintosh.)



Part 4: Errors and Omissions Insurance Personal & Corporate

  Yes, I have E&O Coverage

 

  No, I do not have E&O Coverage

Part 5: Licenses / Professional Designations

Resident State and Insurance License Number:    
    Original Issue Date :      


    Expiration Date :      
 
Professional Designations:

Part 6: Employment History Last 7 Years


Current companies:

 
Company Date of Appointment Agent Number

 
Current/Previous Employers (Must be for past 7 Years)
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    
 
 
Name of Employer:    
Position Held:   
From:           To:    

Part 7: Business and Personal Background Information (Please include complete information and documentation for any 'Yes' answer.)


Have you ever had a claim filed against your E&O policy?Yes   No
Has any insurance company ever terminated your contract for reasons other than lack of production?Yes   No
Have you ever been bankrupt or insolvent, personally or in business?Yes   No
Have you ever had liens or judgements placed against you either personally or in business?Yes   No
Have you ever been investigated by any state insurance department or government agency?Yes   No
Have you ever had an insurance license denied or revoked by a state or other government agency?Yes   No
Has any bonding company denied, paid out on, or revoked a bond for you?Yes   No
Have you ever been convicted or pled guilty or no contest to a crime other tan a misdemeanor?Yes   No
Have you ever been on probation?Yes   No
Are you now the subject of a complaint, investigation, or proceeding that could result ina "yes" answer to any of the above questions?Yes   No


Part 8: Prior Residences (Past Seven Years)


Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    
 
 
Prior Residence Address:    
From:           To:    

Form PPW1