Group Application for Insurance
APEX EXCESS & SURPLUS COVERAGE
Provided through R&Q Quest (SAC) Limited
13253 N. La Montana Dr., Suite 203
Fountain Hills, AZ 85268
R&J Risk Transfer
2435 N. Central Expressway
Richardson, Texas 75080
Section 1. Applicant Information
Authorized Individual Name (Officer or Director):
Federal Employer Identification Number (EIN): Company Type:
Company Address: City: State: Zip:
Section 2. Current Business, Financial and Insurance Coverage Information
A. Financial Information. Please attach copies of the Applicant’s tax returns for the past two years (Form 1065 or 1120, or equivalent) or financial statements for the most recent two years:
B. Your Business. Our underwriters need to understand your business to evaluate and underwrite your Application. Please attach a description of your business or provide us with your business brochures and tell us the address of your company’s website. The information provided should include, but may not be limited to: how revenue is generated, growth of company operations, fixed and variable expenses, operational structure, facilities, locations, use of technology, licenses required, domestic and international operations, general description of proprietary models or processes, and significant business relationships. We may have further questions after we review these materials.
C. Current Insurance Coverage.
When our underwriters evaluate your risk profile, it is important to review coverage. Please attach a copy of all outstanding insurance policies to which the Applicant is either a premium payor or beneficiary. This information may include the carrier, annual premium, coverage limits, benefits and coverage periods. Please also include any claims that have been submitted and the amount of the claim(s) for the last 24 months. The more information you can provide regarding current lines, limits and previous losses is helpful to our team.
Policy 1: Policy 2:
Policy 3: Policy 4:
Section 3. Association Contact
Please list the individual that provided you with this Application. This individual is typically your insurance, legal, tax, accounting, finance or other advisor:
Association Contact Name:
Section 4. Understandings, Representations and Warranties
The undersigned Applicant, by submitting this Application, hereby applies for Excess & Surplus lines insurance coverage as an association benefit through the National Advancing Association Business Organization. Further, the Applicant hereby agrees, understands, represents and warrants the following:
(a) Any and all information and answers provided in this Application are true and correct and can be relied upon by R&Q Quest (SAC), Limited and its affiliates, underwriters, actuaries, accountants, and agents. All information, answers, representations and statements made in this Application are in consideration for the insurance coverage, and are declared to be true, full and complete to the best of the Applicant’s knowledge and belief;
(b) Applicant hereby represents that it has read and understands all the terms set forth in this Application and it is relying solely on the information contained in this Application. In order to purchase insurance coverage, the Applicant must accept all terms contained in this Application and those contained in the Certificate of Insurance issued by R&Q Quest (SAC), Limited. The Applicant may not rely on any other written or oral information provided by others;
(c) The Apex Insurance Premiums are held in a segregated account of R&Q Quest (SAC), Limited. Each Certificate Holder is subject to the losses of the segregated account;
(d) The Applicant is a duly authorized Member in good standing of the Association and is qualified to obtain insurance through the Association;
(e) The Insurer is admitted and licensed under Bermuda Law to provide property and casualty insurance. The insurance may not be available for purchase directly in the United States. Group coverage is only available through participating associations. The enforceability of this insurance coverage is exclusively within the jurisdiction and under the laws of Bermuda. Certificate Holders of Apex understands that in the event Apex book of business is transferred, sold, run-off or otherwise moved to another carrier, coverage will not be impacted other than that being the issuing carrier. Certificate Holder agrees to insurance coverage at the same terms and conditions by the new carrier in the event of transfer of liabilities and/or assets from Apex, as originally underwritten by Apex underwriters;
(f) All claims made under the insurance coverage must be settled or finally adjudicated before the Insurer will make any payments. Insurance coverage will not be paid until all primary insurance reimbursements have been made. Unless otherwise noted in the Applicant’s certificate of insurance, the insurance coverage will not pay for any of the legal fees or costs incurred defending claims or lawsuits. In no event will any amounts be paid until the claim has been settled or finally adjudicated;
(g) Applicant represents that it has reviewed this information and consulted with his or her attorney, CPA, business, insurance and/or financial professionals and that these professionals have determined that Applicant is paying a reasonable premium for the insurance coverage provided based on a review of Applicant’s insurance needs;
(h) This Application constitutes an offer to buy insurance;
(j) As a pre-condition to the payment of any claim under the insurance coverage, Applicant agrees to furnish upon request, satisfactory evidence of claim and furnish information as may be satisfactory to the Insurer in its sole discretion. All claims are made payable to the premium payor unless the Insurer is otherwise notified in writing;
(k) Coverage for which the applicant applies becomes effective only upon acceptance and approval of this Application and the payment of premium has been received by the Insurer. Upon such acceptance, the Insurer will issue a Certificate of Insurance, which will be in-force as of the Effective Date shown on the Certificate of Insurance;
(l) Applicant acknowledges that the terms and conditions of the insurance coverage have been explained and are fully understood by the Applicant. If for whatever reason the Applicant does not understand the insurance coverage, or if for any other reason, the Applicant may cancel the insurance coverage within 30 days for a full refund;
(m) No person or entity has the authority to modify or waive any provision of this Application;
(n) Applicant acknowledges and understands:
(1) It has applied for coverage as an unsolicited benefit through the National Advancing Association Business Organization;
(2) The terms and conditions of the insurance include but are not limited to (please read your certificate of insurance carefully);
(3) The experience adjusted return of earned premium is dependent upon the claims experience of the Apex reserve pool, along with the claims experience of the Applicant;
(4) If after a minimum of 5 (five) years after the first date of coverage listed in the Certificate of Insurance, should any Certificate Holder who elected to terminate insurance under the Policy and Certificate of Insurance, or otherwise would be entitled to a return of premium benefit under the Policy, the Company agrees to return a portion of the premium paid by the Certificate Holder from the inception of insurance using an experience based formula. A Certificate Holder who obtains coverage for less than five (5) years may still be eligible for a return of premium benefit after such time as five (5) years from the date of the first premium payment made under the Policy for the specific Risk(s) of Certificate Holder as determined by the formula below. If after a minimum of 5 (five) years, and the Certificate Holder has terminated its coverage under the Policy, the Company shall deduct a surrender charge of ten (10%) percent from the amount of the experience based premium to be returned. Any amounts returned under the Policy by election of a Certificate Holder before the minimum five (5) year return of premium benefit period shall be subject to the surrender fees in the Policy and listed below. The amount of experience based return premium shall be premiums paid by the Certificate Holder plus assessments paid by the Certificate Holder plus retrospective premium assessments made to the reserve pool allocated on a pro-rata basis less surrender charges less claims made by the Certificate Holder less allocated claims of all Certificate Holders insured in same class of business less amounts held to cover any outstanding liabilities to the Certificate Holder. Insured and Certificate Holder expressly agree that Company retains all rights of authority to manage insurance Company as stated in the Group Policy without consideration of any return of premium benefit(s) which may accrue under the policy;
(5) Insurance Coverage is provided under a retrospective policy. The Company may assess premiums at any time under the Policy if the experience based claims and remaining reserves for any Certificate Holder is inadequate, as determined by the actuaries for the Company, in their sole discretion. No assessment in any single calendar year shall exceed eighty (80) percent of total premiums paid within twelve months of the last claim made by the Certificate Holder;
(6) Surrender charges occurring for amounts returned by request of, and to the Certificate Holder before the required five (5) year return of premium benefit provided under this Policy shall be as follows:
a) A surrender charge of Twelve percent (12%) shall apply to amounts returned after four (4) years through five (5) years from the first date of coverage in the Certificate of Insurance;
b) A surrender charge of Fourteen percent (14%) shall apply to amounts returned after three (3) years through four (4) years from the first date of coverage in the Certificate of Insurance;
c) A surrender charge of Sixteen percent (16%) shall apply to amounts returned after two (2) years through three (3) years from the first date of coverage in the Certificate of Insurance; and
d) A surrender charge of Eighteen percent (18%) shall apply to amounts returned after one (1) year through two (2) years from the first date of coverage in the Certificate of Insurance.
(7) Surrender charge shall be applied to the amount as stated in the return of premium benefit section in the Policy;
(8) Applicant is receiving supplemental insurance, or excess and surplus lines insurance and primary coverage identified in Section 2 is required to be in force throughout the entire term of benefits and that the insurance applied for is secondary;
(9) No representations nor assertions have been made that promise or imply a return on the experience adjusted refund of premiums, or that the Applicant will qualify for such a refund;
(10) Apex Insurance Coverage shall not pay any claims until all primary insurance (if any) has been paid out and exhausted to settle any claims made;
(11) Insurance Coverage is for twelve (12) months and may be renewed. Premium payments are required for each additional period of coverage. Renewals may require additional underwriting, at the sole discretion of the Company;
(12) If the applicant fails to make a timely premium payment, the Insurance Company reserves the right to cancel coverage and return unused premiums to the Applicant, less any applicable surrender fees;
(13) Insurer may cancel the insurance, on either a retrospective or prospective basis, at any time for misrepresentations made in this Application;
(14) If an assessment is made and not fully paid, that coverage can be canceled retrospectively back to the date of this Application;
(15) Insurance coverage is provided by R&Q Quest (SAC) Limited on behalf of Apex, F.B. Perry Building, 40 Church Street, PO Box HM 2062 Hamilton HM HX, Bermuda, a wholly owned subsidiary of Randall & Quilter Investment Holdings plc, London
Please initial if you agree to the understandings, representations and warranties above:
Section 5. Underwriting, Insurable Interest,
Benefits, Payments and Fees
A. Underwriting Analysis. No-cost underwriting evaluations are made available by Insurer and are recommended to each Applicant.
B. Insurable Interest. Applicants must show an insurable interest in the risk for which coverage is sought. The sum of the primary insurance benefits you have through existing policies reflected in Section 2 and the insurance protection under this insurance may not exceed the loss expected in the event of a claim.
C. Payments. Insurance Coverage becomes binding once your underwriting is completed and your premium payment has been accepted. After your Application is approved and your underwriting complete, you will be provided a link to make a payment through our secure portal. You will need your checking account information available to pay your premium in this manner.
For payment by check. Please make your check in the amount of the premium payment payable to: R&Q QUEST (SAC) LIMITED.
Payments may be sent to:
Apex Excess & Surplus
13253 N. La Montana Dr., Suite 203
Fountain Hills, AZ 85268
For payment by wire transfer, please contact your Association Contact.
Any amount of premium financed and accepted for Insurance Coverage from Approved Lenders will be deducted directly from premiums payable (due) in the current accounting period. Financed premiums from outside lenders should be made payable to: R&Q Quest (SAC) Limited.
D. Association Fee. The Apex Excess & Surplus lines insurance coverage is a benefit only offered to current members of the National Advancing Association Business Organization. As a reminder, members must be in good standing which includes the payment of annual membership dues in the amount of $99. If you have not already paid dues this year, you will receive an invoice from The Business Arena. It is important this invoice be paid in a timely manner, so there is no delay in the issuance of your coverage. If you would like, you may include your membership dues along with your premium payment which will be processed on your behalf.
Section 6. Agreement & Endorsement
In Witness Whereof, the Undersigned makes Application for insurance coverage, as described above:
Authorized Individual Name:
I have read the information presented herein;
All information provided is accurate to the best of my knowledge;
No false representations or warranties have been made, nor was any false information provided;
I understand the terms and conditions:
Please enter your initials below to agree the terms and conditions herein:
You acknowledge, by completing and submitting this application you agree to the terms and conditions herein. If you do not agree, please do not submit this application. Thank you.