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Licensed Broker Application

If you are interested in becoming a producer for Clements, please complete and submit the following application. Please note we require a copy of your applicable insurance license(s) and your Errors & Omissions policy. If you have questions regarding these documents or the application, please contact Meg Burris at mburris@clements.com or 1.202.872.0060.

General Information


	(* required field)
	How did you hear about Clements International?*
	Legal Name of Broker*
	Contact Name*
	Mailing and Street Address of Broker:
	Telephone Numbers:
	FAX Number:
	E-Mail Address: *
	Number of Years in the Insurance Business:
	Number of Employees in Your Operation:
	What lines of insurance products do you specialize in?
	Any other information you feel might be useful to us


	License Information (For International Licensed Broker Applicants Only)
			Individual
			Country of Citizenship
			Passport No.:
			Country of Residence:
			Corporation or Company
			Affiliation to any U.S. company, if applicable:
			Where is the company based?
			How many locations?
	What is the name of the regulatory body that oversees the insurance market in your country?
	Do you currently hold any and all licenses/permits required to be in compliance with said regulatory body?

			Yes. License/Permit Number:
			Date Awarded:
			No, for the following reason:
	Note: Please include a copy of your Errors and Omissions Insurance Policy. A minimum of $1 million coverage is required. For US Licensed Broker Applicants Only
			Individual
			Social Security Number:
			Corporation
			State of incorporation:
			Limited or General Partnership
			State of formation:
			Limited or General Company
			State of formation:
			Other
			Describe:
			Federal Tax ID Number
			License(s) held: Agent�s License Broker�s License Consultant�s License
			State(s) of Issuance:
			License Number:
			Date(s) of Issuance:
	Designations and Certificates: (Please attach a copy of any license and designations)


	Property & Casualty		Life & Health	CPCU
	CIC	CISR	LUTCF	CRM
Please include a copy of your Errors and Omissions Insurance Policy. Note: A minimum of $1 million coverage is required. Digital File Upload If you have a digital copy of our appropriate insurance license and/or your Errors & Omissions (E&O) policy you may upload it below. Please click on browse, locate your file(s) and click Open. When you submit your application, your files will upload automatically. File 1: File 2:
Please read the broker agreement and complete the digital signature below to complete your application. PRODUCER AGREEMENT This Agreement is entered into this ____ day of ___________, 2008, by and between Clements & Company, Inc., doing business as Clements International, One Thomas Circle, Suite 800, NW, Washington, DC 20005 (hereinafter referred to as �Clements�) and ___________________________ of ________________ (hereinafter referred to as �Producer�). 1. AUTHORITY AND RESPONSIBILITY In submitting applications for insurance to Clements, Producer, whether an individual, proprietorship, partnership, LLC, corporation or other legal entity, is hereby authorized by Clements to (i) solicit applications for Policies, (ii) deliver approved policy documents provided by Clements to policyholders, and (iii) collect the required deposit premiums payable to Clements and remit same to Clements. It is understood and agreed that the Producer shall not (i) open any bank account or trust account on behalf of, for the benefit of, or containing the name of Clements & Company or any derivative thereof, (ii) advertise or publish any matter or thing, including use of the names, marks, trademarks, or logos of Clements or those of its subsidiaries, affiliates, related companies or insurers concerning Clements or the Clements Products without the express prior written permission of Clements, or (iii) alter, amend or modify Policies for or on behalf of Clements or its insurers. In submitting business to Clements, Producer is agent of or broker for the applicant for insurance and is not acting as an agent, sub-agent or broker for Clements. This Agreement and the relationship between the parties and their officers and employees is not intended and shall not be construed to create a partnership, joint venture or employment relationship. Producer is for all purposes an independent contractor. Producer shall have no authority to bind any insurer for Clements, or act as agent for Clements, or commit to or issue binders, policies, or other written evidence of insurance or make, alter or vary any terms of coverage, or include any liability for Clements. Clements shall have sole right to accept or reject applications for insurance. Clements assumes no responsibility toward any policyholder or Producer with regard to the adequacy, amount or form of coverage obtained through Clements. Producer agrees to hold Clements harmless from any claim asserted against Clements based upon or arising out of acts, errors or omissions of the Producer. 2. DURATION This Agreement shall be continuous unless sooner terminated. Clements or Producer may terminate this Agreement at any time by providing 30 days prior written notice, or in the event of written mutual consent, lesser notice. In the event of a breach of any provision of this Agreement, Clements may terminate this Agreement immediately by providing written notice. Electronic communications shall constitute written notice. After the date of termination of this Agreement, the Producer shall complete collection and account to Clements for all premiums, commissions and other transactions unaccounted for on the date of termination or arising thereafter in respect of outstanding insurances, including but not limited to return premium and return commissions. 3. COMMISSIONS Commissions payable to Producer under this contract shall be subject to the attached Product & Commission Schedule. Producer will receive stated commission within thirty (30) days of the close of the previous month�s production, provided the transaction was completed in the underwriting system before the close of that month, and premium payments due have been received by Clements. 4. ASSIGNMENT OF AGREEMENT It is understood and acknowledged that this Agreement has been entered into by each of the parties based upon reputation, professional competence and financial responsibility. Accordingly, this Agreement may not be assigned to any other party without the prior written consent of the parties hereto. 5. CONFIDENTIALITY Any and all information conveyed between the parties concerning or relating directly or indirectly to the Clements Products and/or the individual policies written for the Clements Products or pursuant to this Agreement is proprietary and confidential to the Producer and Clements. The Parties shall not disclose any such information to anyone outside of organization, or to anyone within their organization other than those individuals who, in the ordinary course of their duties, are responsible for the solicitation, processing or handling of the individual policies written for the Clements Products or except to the extent required to be reported to insurance carriers, administrators, regulatory authorities or by order of law. In the event of any unauthorized disclosure of any confidential or proprietary information by any director, officer or employee of the Parties or their affiliates, the disclosing Party shall be liable to the other Party for any damages suffered as a result of such unauthorized disclosure, including all costs and attorney�s fees incurred in the prevention of any further unauthorized disclosures and the retrieval of any disclosed information. 6. HOLD HARMLESS AND INDEMNIFICATION Each of the parties shall indemnify and hold the other harmless against loss, damages and expenses (including attorney�s fees) resulting directly or indirectly from any violations on any insurance law or regulation and/or any breach of (i) its respective obligations under this Agreement, or (ii) its respective authority hereunder. 7. MISCELLANEOUS PROVISIONS Clements shall be solely responsible for all its expenses incurred in the handling of the Clements Products and Clements operations. Clements is not responsible for any expense incurred by Producer in the solicitation or acceptance of applications for insurance. The Producer hereby warrants to Clements that Producer is properly licensed to transact business as an agent or broker in accordance with the provisions of the insurance laws of the jurisdiction in which the Producer is duly licensed. Producer will promptly notify Clements of any non-renewal, cancellation, suspension, or disciplinary action in respect of its license or licenses. The Producer warrants that it will comply with all applicable laws and regulations governing the conduct of business subject to this Agreement in the jurisdiction(s) involved. Upon written demand, Producer shall supply Clements with copies of all licenses and certificates of qualification, authorization and/or appointment required of a producer by applicable law, rule or regulation in connection with the services to be performed hereunder. A waiver by either of the parties hereto of a specific breach or series of breaches of this Agreement shall not operate as a waiver of any subsequent similar breach or series of breaches. Nothing in this Agreement shall prohibit or in any way restrict Clements from entering into similar agreements at any time with any other producer. Clements agrees, however, to perform its obligations hereunder in such a professional manner consistent with that performed for any other producer. This Agreement, together with any addenda or Product and Commission Schedules attached hereto, constitutes the entire agreement between Clements and Producer and supersedes and replaces any previous agreements between Clements and Producer. No oral promises or representations shall be binding, nor shall this Agreement be modified expect by agreement in writing attached hereto, executed on behalf of Clements. This Agreement is subject to the laws of the District of Columbia. To the extent any provision of this Agreement is or becomes in conflict with such present or future laws or valid regulations or rulings of the appropriate department, then that provision shall be construed in a manner consistent with such law, regulation or ruling. The balance of the Agreement shall remain in full force and effect. Producer shall notify Clements as soon as possible of any claims, suits or notices of loss (or circumstances which might reasonably be expected to result in a claim, suit or notice of loss) and agrees to cooperate fully with Clements and its insurance companies to facilitate the investigation, adjustment, settlement or payment of any claim when and as requested. This Agreement shall be binding upon and shall inure to the benefit of the parties, their successors, assigns and legal representatives. IN WITNESS WHEREOF, the parties have executed this Agreement. _________________________ ________ _______________________ Lloyd Yavener Date Witness VP of Marketing and Creative Services Clements & Company, Inc. _________________________ ________ _______________________ (Producer) Date Witness *I agree to and will adhere to the guidelines set forth by the Broker Agreement above.
Once you have completed the application, please click on the submit button below. Your application will take a few minutes to process, please avoid hitting the submit button again as important information may be lost.