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RLI TRANSPORTATION A Division of RLI Insurance Company

2970 Clairmont Road, Suite 1000

Atlanta, GA 30329

Phone: 404-315-9515 Fax: 404-315-6558

AGENCY/BROKER PROFILE Please type your answers. Use a separate answer sheet if necessary.

A. GENERAL INFORMATION

1. NAME OF FIRM:___________________________________________________________________________

2. PRINCIPAL ADDRESS:_____________________________________________________________________

(STREET) (CITY) (STATE) (ZIP)

3. MAILING ADDRESS:_______________________________________________________________________

(STREET) (CITY) (STATE) (ZIP)

4. PHONE:______________ FAX:_____________ 800:_____________ E-MAIL ADDRESS:______________

5. TYPE OF ENTITY: [ ]CORPORATION [ ]PARTNERSHIP [ ]INDIVIDUAL

6. FEDERAL ID NUMBER:_______________

B. BACKGROUND

1. YEAR BUSINESS ESTABLISHED:_______________

2. DURING THE PAST FIVE YEARS HAS THE FIRM ACQUIRED/MERGED WITH ANOTHER FIRM OR

HAS THE FIRM CHANGED NAMES? [ ]YES [ ]NO

IF YES, PLEASE DESCRIBE:________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

3. IS FIRM ENGAGED IN, OWNED BY, ASSOCIATED OR AFFILIATED WITH, OR CONTROLLED BY

ANY OTHER BUSINESS INTEREST? [ ]YES [ ]NO

IF YES, PLEASE EXPLAIN:_________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

4. ARE YOU A MEMBER OF: [ ]ATA [ ]MCA [ ]OTHER

IF OTHER, PLEASE LIST:___________________________________________________________________

C. PRINCIPALS AND PERSONNEL

1. BREAKDOWN OF PRODUCER’S STAFF (Number): Current Year Prior Year

PRINCIPALS, PARTNERS, OWNERS: ____________ ____________

OFFICERS, MANAGERS: ____________ ____________

BROKERS (Other than above): ____________ ____________

UNDERWRITERS: ____________ ____________

OTHER EMPLOYEES: ____________ ____________

TOTAL STAFF: ____________ ____________

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2. PRINCIPALS, OFFICERS, BROKERS – LIST IN ORDER OF PERCENTAGE OF OWNERSHIP:

TITLE YEAR YEAR

OR STARTED IN STARTED WITH PERCENT

NAME POSITION INSURANCE PRODUCER OWNERSHIP

_______________________ ____________ ___________ ___________ ___________

_______________________ ____________ ___________ ___________ ___________

_______________________ ____________ ___________ ___________ ___________

_______________________ ____________ ___________ ___________ ___________

_______________________ ____________ ___________ ___________ ___________

D. OPERATIONS

1. DOES YOUR FIRM OPERATE AS A WHOLESALER, MGA, RETAILER OR COMBINATION?

______% RETAIL ______% WHOLESALE BROKERAGE ______% MGA BINDING AUTHORITY

2. HOW IS YOUR ORGAINZATION LICENSED, I.E., EXCESS AND SURPLUS LINES BROKER,

REINSURANCE INTERMEDIARY, OR OTHER INSURANCE/REINSURANCE ORGANIZATION?

__________________________________________________________________________________________

__________________________________________________________________________________________

3. LIST STATES WITH LICENSES:

In-Force # Brokers In-Force # Brokers In-Force # Brokers

Business Placing Business Placing Business Placing State License # (Yes / No) Business State License # (Yes / No) Business State License # (Yes / No) Business

AL KY ND

AK LA OH

AZ ME OK

AR MD OR

CA MA PA

CO MI RI

CT MN SC

DE MS SD

DC MO TN

FL MT TX

GA NE UT

HI NV VT

ID NH VA

IL NJ WA

IN NM WV

IA NY WI

KS NC WY

4. IF YOU ARE AN MGA, DO THE RETAIL AGENTS/BROKERS FOR WHOM YOU PLACE BUSINESS

SIGN A CONTRACT REGARDING SUBMISSION OF BUSINESS AND PAYMENT OF PREMIUM?

[ ]YES [ ]NO IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT.

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E. PREMIUM VOLUME AND DISTRIBUTION

1. YOUR TOTAL VOLUME OF BUSINESS: PRIOR CURRENT NEXT YEAR

COMMERCIAL AUTO (Liability)

Large Fleet Truck (26+ power units) ____________ ____________ ____________

Small Fleet Truck (1-25 power units) ____________ ____________ ____________

Public Auto ____________ ____________ ____________

COMMERCIAL AUTO (Physical Damage)

Large Fleet Truck (26+ power units) ____________ ____________ ____________

Small Fleet Truck (1-25 power units) ____________ ____________ ____________

Public Auto ____________ ____________ ____________

CARGO ____________ ____________ ____________

GENERAL LIABILITY ____________ ____________ ____________

EXCESS & UMBRELLA ____________ ____________ ____________

WORK COMP & OCC ACC ____________ ____________ ____________

PROPERTY ____________ ____________ ____________

OTHER ____________ ____________ ____________

Please Describe:____________________________________________________________________________

2. LIST MAJOR COMPANIES IN ORDER OF PREMIUM VOLUME:

BINDING

YEARS ANNUAL LOSS AUTHORITY NUMBER

NAME REPRESENTED VOLUME RATIO (YES / NO) YEARS

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

______________________ ______________ __________ ______ ____________ _________

3. DESCRIBE SCOPE OF BINDING AUTHORITY. I.E.: LIMIT OF AUTHORITY, LINES, ETC.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

4. COMPANIES DISCONTINUED IN THE LAST FIVE YEARS:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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5. DO YOU ADJUST CLAIMS FOR ANY COMPANIES YOU REPRESENT? [ ]YES [ ]NO

IF YES, PLEASE EXPLAIN:_________________________________________________________________

_________________________________________________________________________________________

6. DESCRIBE ANY SAFETY OR LOSS CONTROL SERVICES PROVIDED BY YOUR ENTITY:

__________________________________________________________________________________________

__________________________________________________________________________________________

F. PRODUCTION TO COMPANY

ANTICIPATED VOLUME TO COMPANY WILL COME FROM THE FOLLOWING SOURCES:

LF TRUCK SF TRUCK PUBLIC AUTO

(26+ Units) (1-25 Units)

1. NEW BUSINESS ___________ ___________ ______________

2. TRANSFER FROM CURRENT COMPANY ___________ ___________ ______________

3. TRANSFER FROM DISCONTINUED COMPANY ___________ ___________ ______________

4. TOTAL (1+2+3) ___________ ___________ ______________

COMMENTS:______________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

G. FINANCIAL INFORMATION

IF NOT HANDLED BY MAIN OFFICE, PROVIDE ADDRESS:

1. ADDRESS:_____________________________________________________________________

(STREET) (CITY) (STATE) (ZIP)

2. PHONE:______________ FAX:_____________ 800:_____________ E-MAIL ADDRESS:______________

3. NAME OF ACCOUNTING CONTACT:________________________________________________________

4. BANK REFERENCE:_______________________________________________________________________

NAME:___________________________________________________________________________________

TRUST ACCOUNT #:_______________________________________________ OTHER:________________

BANK ADDRESS:__________________________________________________________________________

BANK CONTACT:__________________________________________________ PHONE:_______________

ATTACH COPY OF LATEST FINANCIAL STATEMENT.

5. DO YOU MAINTAIN FIDELITY COVERAGE? ARE OFFICERS COVERED?

[ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING:

INSURANCE COMPANY:___________________________________________________________________

POLICY LIMITS:___________________________________________________________________________

POLICY DEDUCTIBLE:_____________________________________________________________________

EXPIRATION DATE:_______________________________________________________________________

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6. DO YOU MAINTAIN E & O COVERAGE? [ ]YES [ ]NO IF YES, PROVIDE THE FOLLOWING:

INSURANCE COMPANY:___________________________________________________________________

POLICY LIMITS:___________________________________________________________________________

POLICY DEDUCTIBLE:_____________________________________________________________________

EXPIRATION DATE:_______________________________________________________________________

7. HAS ANY MEMBER OF YOUR FIRM RECEIVED ANY DISCIPLINARY ACTION BY A STATE

INSURANCE DEPARTMENT OR OTHER REGULATORY AUTHORITY? [ ]YES [ ]NO

IF YES, EXPLAIN:_________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

8. IS THERE ANY PENDING OR THREATENED LITIGATION OR JUDGEMENTS WITHIN THE PAST

FIVE YEARS EXCEEDING $10,000 AGAINST THE BROKER OR ANY OF THE PRINCIPALS?

[ ]YES [ ]NO IF YES, EXPLAIN:_________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

THE UNDERSIGNED HEREBY DECLARES THAT THE ANSWERS GIVEN WITH RESPECT TO THE

FOREGOING QUESTIONS ARE TRUE, COMPLETE AND ACCURATE WITH NO

MISREPRESENTATIONS, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT.

SIGNATURE OF APPLICANT:__________________________________

TITLE OF APPLICANT:________________________________________

DATE OF SIGNATURE:________________________________________

***** BE SURE TO INCLUDE COPIES OF THE FOLLOWING DOCUMENTS:

1. LICENSES 2. FINANCIALS – P&L AND BALANCE SHEET 3. E & O DEC PAGE

RETURN TO:

ATTENTION: LICENSING

RLI TRANSPORTATION

2970 CLAIRMONT ROAD, SUITE 1000

ATLANTA, GA 30329