Program insurance is administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers, LLC in California #0795478 (“Lockton Affinity”). Coverage may not be available in all states and is subject to actual policy terms and conditions. Policy benefits are the sole obligation of the issuing insurance company. Coverage is provided by Lloyd’s of London. Program sponsor may receive a royalty fee for the licensing of its name and trademarks as part of the insurance program offered to its members.
You warrant that the information provided in the Application for Insurance (the “Application”) is true and accurate. The information provided in the Application is relied upon in determining the eligibility for the insurance coverage offered. Any materially false statements with respect to the Application may result in a denial of coverage for a specific loss and/or void the policy entirely. Please see specific fraud warnings set forth below.
A.M. BEST CARRIER RATING
Lloyd’s of London is rated "A" for financial strength by A.M. Best indicating the company's ability to meet its ongoing insurance policy and contract obligations. More detailed information about A.M. Best Company and their rating methodology can be found at www.ambest.com
Lockton Affinity has not performed an independent financial analysis, and, as such, cannot guarantee or make any representations in regard to the financial condition of Lloyd’s of London or any other insurance companies with which we place business.
SURPLUS LINES INSURANCE/NON-ADMITTED CARRIER
Lloyd’s of London is an excess/surplus lines insurer which is not licensed by or subject to the supervision of the insurance department of your state of residence. Policy coverage forms and rates are not subject to regulation by the insurance department of your state of residence. Excess/surplus lines insurers do not generally participate in state guaranty funds and therefore insureds are not protected by such funds in the event of the insurer’s insolvency. Lockton Affinity is not an agent of Lloyd’s of London because surplus lines insurers are not permitted to appoint insurance producers. In accordance with applicable state law, insurance premiums, the administration fee and association membership dues, if any, are subject to applicable taxes.
FULLY EARNED PREMIUM, FEES AND CHARGES
You acknowledge that the coverages quoted are subject to payment of premiums, and include broker compensation (including standard commission) paid by the carrier and a program administration fee paid by you.
All collected premium shall be deemed fully earned at the commencement of the policy period. If the policy is cancelled, the carrier will not be liable to return any collected premium. The following policy charges or fees shall also be deemed fully earned at the commencement of the policy period, even if the policy is later cancelled: (1) broker administration fee, (2) surplus lines taxes & fees, (3) broker compensation from the carrier, and (4) Risk Purchasing Group fees (if applicable).
I elect to have future premiums automatically charged to the credit card/debit card used for this
transaction. I can cancel this agreement by email to firstname.lastname@example.org or by mailing notice of such cancellation to Lockton Affinity, LLC, P.O. Box 410679, Kansas City, MO 64141-0679. Any such cancellation must be in writing, and must be received by Lockton Affinity at least ten (10) days before the next charge date in order to cancel the next payment. If the amount of my premium payment or my payment schedule changes, Lockton Affinity will notify me at least 20 days before the payment date.
PLEASE CAREFULLY REVIEW THESE DISCLOSURES CONCERNING THE ONGOING BILLING AGREEMENT. IT IS RECOMMENDED THAT YOU PRINT OR SAVE A COPY FOR YOUR RECORDS.
DISCLOSURES PERTAINING TO ONGOING BILLING AGREEMENT
- Continuous Payment. Future premiums will automatically be charged to your credit card/debit card as they become due.
- Payment Schedule and Duration. Monthly or annual payments for such premiums, as the case may be, will be charged to your credit card/debit card on the day you purchase your initial policy and, thereafter, on subsequent monthly payment dates or the policy effective date of each subsequent renewal, continuing until (1) you cancel your ongoing payment authorization; (2) you cancel your policy; or (3) your policy otherwise expires.
- Payment Amount. The amount that will be automatically charged every month or year is the amount set forth in your receipt.
- Description of Charges on Billing Statement. The ongoing billing charges will be listed as “Lockton Insurance Online” on your billing statement.
- Changes in Premium Amount. If the amount of your premium payment or payment schedule changes, Lockton Affinity will notify you at least 20 days before the next payment date.
- Cancellation of Ongoing Payment Authorization. You have the right to cancel ongoing payments at any time. If you desire to do so, you can do so by email to email@example.com or by mailing notice of such cancellation to Lockton Affinity, P.O. Box 410679, Kansas City, MO 64141-0679. Any such request for cancellation must be in writing, and must be received by Lockton Affinity at least 15 days before the next ongoing billing date in order to cancel the next payment. Any request to cancel ongoing billing will be treated as a request to cancel your policy. Ongoing payment authorization is a requirement for all policyholders.
- Questions and Assistance. If you have questions about your ongoing payment authorization or otherwise need assistance, including assistance with cancelling ongoing billing, you can call Customer Service at 877-672-3006, Option 3.
ADDITIONAL DISCLOSURES FOR ECHECK AUTHORIZATION FOR RECURRING BILLING
- Required Language. Consumer is advised on the day this application is submitted, that by entering your routing and account numbers and submitting the application, you are authorizing payment in the amount and frequency quoted to be processed as electronic funds transfers (EFT) or drafts drawn from your checking or savings account as indicated and, if necessary, electronic credits to your account to correct erroneous debits. Your payment will process within 1-2 banking days. PLEASE PRINT A COPY OF THIS PAGE FOR YOUR RECORDS. ALTERNATIVELY, CONTACT US AT 877-672-3006, Option 3.
- Internet Check Acceptance – Recurring Payments. By entering your routing and account number and clicking “SUBMIT”, you authorize your payments to be processed as electronic funds transfers (EFT) or drafts drawn from your checking or savings account as indicated and, if necessary, electronic credits to your account to correct erroneous debits.
Disclosure of Credit Card and Debit Card Data to Insurance Providers and Third Parties Processing Payment. If you choose to make a purchase through our website using a credit card or debit card, then your credit/debit card information will be collected and processed by Lockton Affinity’s payment processing vendors. By submitting your credit/debit card information via this website, you consent to have your payment information stored until you cancel ongoing payment authorization. Although Lockton Affinity takes steps to confirm that its third party processing vendors have adequate privacy protections in place and requires such processing vendors to comply with all applicable data privacy laws and regulations, Lockton Affinity cannot guarantee the data privacy practices of any third party. By submitting your credit card/debit card information via this website, you consent to the collection, processing and usage of credit/debit card information by Lockton Affinity, your insurance provider, and by any third-party vendors assisting with credit and debit card transactions. If you do not consent to this, do not provide payment information via this website.
You acknowledge that:
Lockton Affinity, as the insurance agent and administrator for the program, will not release any of your individual insurance policy information to any party without your express written consent. This includes but is not limited to policy documents, expiration dates, or any personally identifiable information provided in order to bind your coverage. Lockton Affinity will receive certain compensation, including standard commission, from a carrier, intermediary or other third party as a result of the sale of insurance to you. These commissions received are for the placement/renewal of your insurance policy, day-to-day servicing, and/or other services Lockton Affinity has agreed to provide on your behalf. In addition, Lockton Affinity, in its role as administrator of the program, will charge a program administration fee which compensates Lockton Affinity for services performed, and related costs incurred, for association members. This charge is not part of any premium paid to any carrier and is non-refundable in the event of policy or membership cancellation.
Lockton Affinity may also be eligible to receive other forms of compensation such as incentive or contingency payments or bonuses and/or supplemental commissions from carriers, intermediaries (which may be affiliated with Lockton Affinity) or other third parties as a result of being an insurance broker (collectively, “Additional Compensation”). Contingency payments or bonuses are based on the overall performance of a partial or entire book of business Lockton Affinity places with a carrier, and Lockton Affinity’s eligibility and the amount of any such compensation may vary depending on the line of business and a number of “contingent” factors related to future performance such as overall premium volume, premium growth year-over-year, persistency, profitability and/or retention targets set by the carrier. As such, a contingency payment received by Lockton Affinity from a carrier is difficult to tie back to any particular insurance policy. Additional Compensation in the form of supplemental commission is established at the beginning of each calendar year based on Lockton Affinity’s historical and current performance typically measured using some or all of the same performance factors by which contingency payments are calculated. Lockton Affinity may also receive service fees from carriers for consulting and/or administration services specific to a carrier. These service fees are not tied to, dependent on or identified with any particular insurance placement. By submission of payment pursuant to this order, you consent and agree to Lockton Affinity’s ability to receive the compensation outlined herein under all circumstances.
NEW YORK REGULATION 194 DISCLOSURE
The following disclosure is provided pursuant to New York State Insurance Department Regulation 194 (11 NYCRR 30.1, et seq.):
Lockton Affinity is an insurance producer licensed by the State of New York. Insurance producers are authorized by their license to: confer with insurance purchasers about the benefits, terms, and conditions of insurance contracts; offer advice concerning the substantive benefits of particular insurance contracts; sell insurance; and obtain insurance for purchasers. The role of an insurance producer in any particular transaction typically involves one or more of these activities.
Lockton Affinity may be eligible to receive compensation from the selling insurer or other third party based in whole or in part on the insurance contract(s) sold to you. Such compensation may vary depending on a number of factors, including the insurance contract(s) and the insurer(s) that you select. In some cases, other factors may affect the total compensation Lockton Affinity receives, such as the volume of business Lockton Affinity provides to an insurer and / or the profitability of the insurance contracts Lockton Affinity provides to an insurer.
You may request additional information about the compensation expected to be received by Lockton Affinity based in whole or in part on the sale of insurance to you and / or any alternative quotes presented to you by Lockton Affinity.
General Fraud Warning Statement:
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV:
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. *Applies in MD only.
Applicable in CA:
For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Applicable in CO:
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
Applicable in FL and OK:
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony (of the third degree)*. *Applies in FL only.
Applicable in KS:
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)**. *Applies in PA only. ** Applies in NY only.
Applicable in ME, TN, VA, and WA:
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME only.
Applicable in NJ:
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR:
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
Applicable in PR:
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
ELECTRONIC DELIVERY OF POLICY DOCUMENTS
By agreeing to pay the quoted premium and directing Lockton Affinity to bind coverage on your behalf, you also consent and agree to receive your insurance policy documents in an electronic format including:
- Your insurance policy including the policy declarations and policy coverage forms and endorsements.
- Other supporting documents in connection with your insurance policy including but not limited to billing statements, legally required notices and other official correspondence.
- Notices of Cancellation
- Notices of Nonrenewal
This consent applies to all policies you purchase on this website.
You have the right to:
- Select paper delivery and withdraw your consent to receive your insurance policy/coverage documents and/or other supporting documents in connection with your insurance policy in an electronic format.
- Select paper delivery in addition to electronic delivery.
You agree that the email address you have provided in your application is current and that you are able to access the policy documents, other supporting documents and notices sent to your email address. You also agree to notify us at the address provided below of any changes in your email address.
To elect an option other than electronic delivery please contact your Client Solutions Representative at:
877-672-3006, Option 3
To update your electronic mail address, please contact your Client Solutions Representative at:
877-672-3006, Option 3
This policy is not subject to the protection of any guaranty association in the event of liquidation or receivership of the insurer.