PRODUCER AGREEMENT · PRODUCER AGREEMENT This agreement is made and entered into as of the date set...

Special Risks Limited, LLC20 Gold St , PO Box 1250 Agawam, MA, 01001

www.specialrisksltd.com

PRODUCER AGREEMENT

This agreement is made and entered into as of the date set forth below by and between Special Risks Limited LLC, aSubsidiary of Specialty Program Group, LLC, a Delaware corporation (“Special Risks Limited”), and the agent or agency(“Producer”) set forth below.

RECITALS

Whereas, Special Risks Limited represents insurance companies and similar entities in the placement and writing ofinsurance; and

Whereas, Producer requires the services of Special Risks Limited to place insurance for its clients also referred to asinsured’s and/or the insured’s agent, broker or representative; and

Whereas, Special Risks Limited and Producer desire to enter into an Agreement, which includes a commissionarrangement and independent control by Producer of the insurance business placed through Special Risks Limited, and anunderstanding of the rights and obligations of each:

Now, in consideration of these mutual agreements, the sufficiency of which is acknowledged, it is agreed as follows:

ARTICLE 1: SCOPE OF AGREEMENT

This Agreement governs the relationship between Special Risks Limited and Producer and is binding upon the parties andtheir respective heirs, successors and assigns. It is further understood that this Agreement replaces any prior agreementbetween the parties, constitutes the entire agreement of the parties, and may not be changed or modified unless inwriting, signed by the parties.

ARTICLE 2: PRODUCER’S STATUS AND DUTIES

a. It is understood that Producer is an independent contractor and not an agent of Special Risks Limited. Producer hasno authority to bind business with Special Risks Limited or any insurance company or underwriter represented bySpecial Risks Limited.

b. Producer shall have ownership of all business subject to this Agreement. Producer agrees to keep complete recordsand accounts of all transactions and will allow Special Risks Limited to inspect and audit all such records andaccounts.

c. Producer acknowledges its duty to fully inform its clients of the terms, conditions, exclusions and limitations of anyinsurance placed through Special Risks Limited. Producer further acknowledges its responsibility with respect toproper coverage for its clients, disclosure of all fees, review of all quotes, policies and binders for accuracy and tokeep Producer’s clients fully informed about issues, including but not limited to the use of non-admitted insurers.

ARTICLE 3: PLACEMENT OF ORDERS

Producer shall follow all applicable state laws prior to placing any order for insurance or excess and surplus linesinsurance with Special Risks Limited. Coverage may only be bound in writing; oral telephonic communication is notsufficient. Facsimile or electronic communications are acceptable if signed originals are forwarded on the day of signingto Special Risks Limited. Receipt of payment with or without application for a policy will not constitute automatic bindingof coverage for said policy.

ARTICLE 4: LICENSINGProducer warrants that it is properly licensed to sell insurance in its state of domicile, and all other states in whichProducer sells insurance, and agrees to act in compliance with all laws and regulations regarding placement ofinsurance with admitted and/ or non-admitted insurance companies in each state.

ARTICLE 5: PREMIUM PAYMENT

Special Risks Limited LLC , a Subsidiary of Specialty Program Group, LLC Producer Agreement 01/2020

Producer Initials: _________ Special Risks Limited Initials: _________

http://www.specialrisksltd.com/



Special Risks Limited BILLED: (AGENCY BILL)Producer guarantees payment to Special Risks Limited, all premiums, including fees and taxes, billed to Producer bySpecial Risks Limited on or before the due date, for all policies placed by Producer, notwithstanding the ability ofProducer to collect premiums from the insured and without regard to any financing agreement. If Producer does not paySpecial Risks Limited within the time specified, Special Risks Limited and the carrier are authorized to cancel anycertificate or policy for which Special Risks Limited or the carrier have not been paid, and Producer agrees to pay theearned premium on such canceled documents. In the event the Producer is unable to collect audit premium from theinsured, the Producer may return an uncollected invoice to Special Risks Limited along with documentation of its effortsto collect the premium, within 30 days of the invoice date provided the insurance company accepts such a returnedinvoice for its direct collection.

CARRIER BILLED: (DIRECT BILL)Producer guarantees payment to Special Risks Limited and its direct bill carrier, all initial or deposit premiums,including fees and taxes billed by either Special Risks Limited or its direct bill carrier, on or before the due date for allpolicies ordered or placed by Producer, notwithstanding the ability of the Producer to collect premiums from theinsured and without regard to any financing agreement. If Producer or its client does not pay Special Risks Limited orSpecial Risks Limited’s direct bill carrier within the time specified, Special Risks Limited and the direct bill carrier areauthorized to cancel any certificate or policy for which Special Risks Limited or its direct bill carrier have not been paid,and Producer agrees to pay the earned premium on such canceled documents.

ARTICLE 6: CANCELLATION

There shall be no flat cancellation of any insurance coverage bound and/or written at the request of Producer, except asprescribed by law. Any and all coverage affected by Special Risks Limited at the request of Producer are submitted withthe understanding that they are not subject to flat cancellation, and will be canceled in accordance with the policy issuedand the insurance carrier’s procedures. In consideration of the commission allowed to Producer on all premiums, theProducer agrees to refund commission on all returned premiums at the same rate at which such commission wasoriginally paid.

ARTICLE 7: ACCOUNTING

Producer will pay in accordance with terms provided by Special Risks Limited or its carrier on invoices provided toProducer. The payment must be mailed, wired or electronically transmitted in time to reach our Woodbury, New Yorkoffice or the carriers direct bill address no later than the date indicated on each invoice. When a discrepancy exists inaccounting between Producer and Special Risks Limited, it shall be Producer’s responsibility to notify Special RisksLimited within ten (10) days from receipt of invoice of amounts in variance with Special Risks Limited records.

ARTICLE 8: CLAIMS AND REPORTS OF LOSSES

Producer agrees to report, immediately upon receipt, any claim, loss or possible claim or loss it has knowledge of toSpecial Risks Limited or the insuring carrier and to immediately report, in writing, any fact, occurrence, or incident thatmay result in a loss or claim, under any policy of insurance placed through Special Risks Limited. Producer does nothave authority to adjust, handle, investigate or provide coverage opinions regarding any claim, loss or occurrence.

ARTICLE 9: INDEMNIFICATION

Producer shall indemnify and hold harmless Special Risks Limited and the insurance companies it represents from anyand all claims, suits, actions, judgments, loss or expense, including legal fees which Special Risks Limited may incur as aresult of any act, error or omission, or breach of this agreement, including any failure of Producer or any of its agents oremployees to act. Special Risks Limited shall indemnify and hold harmless Producer from any and all claims, suits,actions, judgments, loss or expense, including legal fees which Producer may incur as a result of any act, error oromission, or breach of this agreement, including any failure of Special Risks Limited or any of its agents or employees toact.ARTICLE 10: ERRORS AND OMISSIONS INSURANCE






Producer agrees to maintain, at all times this Agreement is in effect, errors and omissions coverage for itself and itsagents, solicitors and employees in an amount not less than $1,000,000 per incident. A Certificate of Insuranceconfirmation of coverage will be submitted annually to Special Risks Limited.

ARTICLE 11: TERMINATION

This Agreement may be terminated at any time by either party upon written notice mailed to the last known address ofthe other party. Termination of this Agreement will not affect the provisions of this Agreement with regard to any policyof insurance placed through Special Risks Limited during the term of this Agreement.

ARTICLE 12: INFORMATION UPDATES

By signing below Producer acknowledges they have requested ongoing information via email or fax regarding new oramended Special Risks Limited products. If you do not wish to receive ongoing information, simply strike throughArticle 12.

ARTICLE 13: GOVERNING LAW

Agreement shall be subject to and governed by the laws of the State of Texas.

FOR THE PRODUCER FOR Special Risks Limited

David Florian, President

Printed Name and Title Printed Name and Title

Signature Signature

Date Date

COMPANY/AGENCY NAME

Special Risks Limited LLC

Division of Specialty Program Group LLC

180 River Road 2nd Floor

Summit, NJ 07901

D: (215) 809-2161

F: (215) 754-4422

Physical Address

City, State ZIP

Mailing Address (if different from above)

City, State ZIP

Telephone Number

Fax Number

E-mail Address

Federal EID#

Please complete and return with a copy of your agency license and proof of E&O insurance.






PRODUCER PROFILE

PLEASE CHECK ONE: New Client Existing Client

Purchase of the following Existing Client:

Other (please explain)

How did you learn about Special Risks Limited?

SpecialRisksLtd.com Trade Publication E-mail Blast Employee

Referral: Tradeshow Other:

PRODUCER NAME:

1) Top 3 Insurers Premium Volume

2) Premium Allocation

Commercial % Personal % Life & Health % Excess & Surplus %

3) Office Location(s) a)

b)

4) Marketing Manager Name

E-mail Phone

5) Agency Principal or Name

Executive Officer E-mail Phone

6) Number of Producers Number of Employees

Premium Payment Mailing AddressSpecial Risks Limited

A Subsidiary of Specialty Program Group LLC

20 Gold St, PO Box 1250

Agawam, MA 01001




2/13/2017

Agency/Agent Setup Form

NATURE OF REQUEST: DATE: PLEASE COMPLETE THE REQUIRED SECTIONS AND THE APPLICANT’S STATEMENT REGARDING CONSUMER REPORTS PLEASE BE SURE TO READ THE DISCLOSURE REGARDING CONSUMER REPORTS **NOTE: ALL LICENSED AGENTS WITHIN THE OFFICE SHOULD COMPLETE AND RETURN THE FORM** ** INFORMATION PROVIDED IN THIS FORM MAY BE USED BY THE COMPANIES OF AMERICAN MODERN TO FILE NOTICE OF APPOINTMENT WITH A STATE DEPARTMENT OF INSURANCE AS DETERMINED NECESSARY BY COMPANY **

NAME OF AGENCY (AS LICENSED):

DBA OR C/O (IF APPLICABLE):

AGENCY FEDERAL TAX ID: AGENCY EMAIL ADDRESS:

E&O CARRIER:

E&O POLICY NUMBER: E&O POLICY LIMITS:

E&O POLICY EFFECTIVE DATE: E&O POLICY EXPIRATION DATE:

Licensed states Requested :

All 50 States & DC AL AK AZ AR CA CO CT DC DE FL

GA HI ID IL IN IA KS KY LA ME MD MA MI MN

MS MO MT NE NV NH NJ NM NY NC ND OH OK OR

PA RI SC SD TN TX UT VA VT WA WI WV WY

Assigned sub code (if applicable):

TO BE COMPLETED AND SIGNED BY THE AGENCY PRINCIPAL/OWNER:

I, the undersigned, hereby represent that I, or my duly authorized representative, have affiliated all producers/agents that are required by law to be affiliated with the Agency. I further represent that I, or my duly authorized representative, will affiliate with the Agency any producers/agents that are required to be affiliated in the future.

Signature Printed Name Date

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Licensed Individual

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2/13/2017

Agency/Agent Setup Form LAST NAME: FIRST NAME:

MIDDLE NAME: MAIDEN NAME:

GENDER: Male Female DATE OF BIRTH: EMAIL ADDRESS:

NAME OF AGENCY (AS LICENSED):

PRINCIPAL/OWNER OF AGENCY:

OFFICE LOCATION ADDRESS:

CITY: STATE: ZIP CODE:

OFFICE MAILING ADDRESS (IF DIFFERENT FROM LOCATION ADDRESS):


AGENCY PHONE #: AGENCY FAX #:

Username for Single Sign On (if applicable):

IF YOU HOLD A VALID AGENT LICENSE, PLEASE COMPLETE THE FOLLOWING , READ THE DISCLOSURE REGARDING CONSUMER REPORTS AND COMPLETE AND SIGN THE APPLICANT’S STATEMENT REGARDING CONSUMER REPORTS

RESIDENCE ADDRESS:


SOCIAL SECURITY #: NPN (NATIONAL PRODUCER NUMBER):

LANGUAGES SPOKEN: ENGLISH SPANISH CHINESE VIETNAMESE

JAPANESE FILIPINO KOREAN OTHER

Licensed states Requested :

All 50 States & DC AL AK AZ AR CA CO CT DC DE FL

GA HI ID IL IN IA KS KY LA ME MD MA MI MN

MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

ANY ADDITIONAL COMMENTS FOR SETUP:

** INFORMATION PROVIDED IN THIS FORM MAY BE USED BY THE COMPANIES OF AMERICAN MODERN TO FILE NOTICE OF APPOINTMENT WITH A STATE DEPARTMENT OF INSURANCE AS DETERMINED NECESSARY BY COMPANY **

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DISCLOSURE REGARDING CONSUMER REPORTS

Pursuant to the Fair Credit Reporting Act ("FCRA") (15 USC 1681b, 1681d), the following disclosure is required.

1. One or more of the affiliated companies of American Modern Insurance Group, Inc. (hereinafter "Company") may obtain a consumer report regarding you for the purpose of determining whether to enter into an agency relationship and/or to appoint you as our agent.

2. If you are appointed as an agent, the Company may obtain consumer reports concerning you from time to

time, and may use the consumer reports in deciding whether to continue, revoke, or terminate your appointment as an agent, or to otherwise change the terms of the agency relationship with you.

3. The types of consumer reports the Company may obtain with respect to you include criminal background

checks, and may include information on your character, general reputation, personal characteristics, and mode of living.

4. Please complete the Applicant’s Statement Regarding Consumer Reports and sign to indicate that you agree that we may obtain a consumer report(s) regarding you. Note that prior to taking any adverse action, a copy of your consumer report(s) and a summary of rights will be sent to the address listed below (or, if no address is listed below, the address that we have on file).

Minnesota and Oklahoma residents only: If you would like a copy of the consumer report prepared on you , please check this box: □

California residents only: You may view the file on you by contacting General Information Services, Inc. (“GIS”) 866‐265‐4917 during business hours and on reasonable notice. You may obtain a copy of this file at their office with proper ID and paying the costs to copy. You may be accompanied by one other person who shall furnish reasonable identification. You may make a written request, with proper identification, to have your file sent by certified mail to a specified address; however GIS shall not be liable for disclosures to third parties caused by mishandling after such mailings leave GIS. A summary of information will be provided by telephone, if you make a written request with the proper ID for disclosure, and toll charges, if any, for such a telephone call shall be prepaid or charged directly to you. General Information Services, Inc.’s website is www.geninfo.com.

2/13/2017

Applicant's Statement Regarding Consumer Reports

I have received and read the Disclosure Regarding Consumer Reports above, advising me that the Company may obtain consumer reports about me. I understand that the Company is not permitted to obtain such consumer reports unless I authorize it to do so.

By signing below, I authorize the Company to obtain consumer reports about me. I authorize and direct each and every consumer reporting agency to provide consumer reports about me to the Company at its request.

Dated:

Signature of Applicant:

Printed Name of Applicant:

Address:

City/State/Zip:

Agency Code:

Producer/Sub Number:

.257..

PRODUCER AGREEMENT · PRODUCER AGREEMENT This agreement is made and entered into as of the date set...

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