NAMED INSURED

POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy
Client Information
Client Name: Pol No:
FORMS LIST
Are all Forms Attached?
Has a New Form Been Added to Policy this
year that was NOT on expiring Policy? If so,
list the form number.
Has a Form Edition Date Changed on
RENEWAL policy? If so, list.
Is a Form listed on EXPIRING Policy that is
NOT listed on the Renewal Policy? If so list.
ADDITIONAL COMMENTS
 Binder Expired Policy Status COMMENTS
Information
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
Client Information
Client Name: Pol No:
BILLING INFO
Status
Policy Number
Effective Date
Expiration Date
Issuing Company
Billing Company
Policy Type / Coverage Code (USD)
Commission
Direct/Agency Bill
Premium
Is servicer correct?
INVOICING
Any Premium Amount Invoiced?
ADDITIONAL COMMENTS
COMMENTS
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status COMMENTS
Commercial Application
Applicant Information
Named Insured MATCHES
Named Insured Schedule MATCHES
Mailing Address MATCHES
FEIN Number
Type of Entity MATCHES
Premises/Locations
Location Schedule MATCHES
Does numbering of locations match between
USD and New / Renewed Policy?
Prior History
Has it been updated with last year's
information? UPDATED
ADDITIONAL COMMENTS
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
PROPERTY
Client Name: Pol No:
LOCATIONS
Locations
COV
COMML PROP LOCATION SPECIFIC COVERAGE
Subject of Insurance
Amount
Coin%
Val (Valuation)
Cause of Loss
Deductible
COMML PROP BLANKET COVERAGE
Subject of Insurance
Limits
Coin%
Val (Valuation)
Cause of Loss
Deductible
ADDITIONAL/OTHER INTEREST
Additional Interest Name(s)*
ADDITIONAL COMMENTS
COMMENTS
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status COMMENTS
GENERAL LIABILITY
Client Name: Pol No:
LOCATIONS
Locations
REMARKS
Remarks NOT LISTED
If Hired/Non-Owned coverage includes in
expired policy it should be include in
renewal policy, if not
say NO ans keep DOESN't MATCH
(Applicable only for the state CA)
COV
COVERAGES
Claims Made/Occurrence
If Claims Made, Retro Date
LIMITS
General Aggregate
Products & Completed Ops Aggregate
Personal & Advertising Injury
Each Occurrence
Damage to Rented Premises (Fire Legal)
Medical Payments
Hired and Non-Owned Liability
DEDUCTIBLE
Deductible Amount
Deductible Basis
EMPLOYEE BENEFITS LIABLITY
Employee Benefits Liability Limit
Employee Benefits Liability Claims Made or
Occ
Employee Benefits Liability Claims Made
Retro date
Employee Benefits Liability Deductible
UNDERWRITING
HAZARD/CLASSIFICATION
Loc# / Bldg#
Event(s)
Class Code
Premium Basis
Premium Basis Exposure
ADDITIONAL/OTHER INTEREST
Additional Interest Name(s)
ADDITIONAL COMMENTS
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
COMMERCIAL AUTO
Client Name Pol No.
Basic Coverages
Liability Symbol / Limit
PIP Symbol / Limit
Medical Payments Symbol / Limits
UM Symbol / Limits
UDM Symbol / Limits
Hired & Borrowed State & Cost of Hire
Non-owned Liability
Physical Damage Coverage & Symbols
Hired Car Physical Damage Primary Yes/No
Hired Car Physical Damage Limit
Hired Car Physical Damage Deductible
Named Drivers List*
VEHICLES
Vehicle Number

Does numbering of vehicles match between

Applied and New / Renewed Policy?

Vehicle Year
Vehicle Make
Vehicle Model
Vehicle VIN#
Cost New
Class Code
Terriotry
Garage City
Garage State
If Non-Owned Auto
Number of Employees
Number of Volunteers
COVERAGES
Liability
PIP
UM
UDM
Med Pay
Coverage Options - specified causes of loss
or Comp / Collison
ACV, Agreed Amt, or Stated Amt
Specified Cause of Loss
Comp Ded
Collison Ded
Rental Reimbursement
Towing and Labor
ADDITIONAL/OTHER INTEREST
Additional Interest Name(s) / Loss Payee
ADDITIONAL COMMENTS
COMMENTS
 Garage Liability
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status COMMENTS
Garage Liability
Client Name: Pol no:
Garage Liability Basic Coverages
Liability Symbol / Limit
Bodily Injury & Property Damage
Medical Payments Symbol / Limits
UM Symbol / Limits
UDM Symbol / Limits
Garagekeepers Coverage - Direct Primary
Physical Damage Coverage & Symbols
Broad Form Products
Broad Form Completed Operations
Deductible
Garage Liability Errors & Omission
Limit
Deductible
VEHICLES
Vehicle Number

Does numbering of vehicles match between

Applied and New / Renewed Policy?

Vehicle Year
Vehicle Make
Vehicle Model
Vehicle VIN#
Cost New
Class Code
Terriotry
Garage City
Garage State
If Non-Owned Auto
Number of Employees
Number of Volunteers
COVERAGES
Liability
PIP
UM
UDM
Med Pay
Coverage Options - specified causes of loss
or Comp / Collison
ACV, Agreed Amt, or Stated Amt
Specified Cause of Loss
Comp Ded
Collison Ded
Rental Reimbursement
Towing and Labor
ADDITIONAL/OTHER INTEREST
Additional Interest Name(s) / Loss Payee
ADDITIONAL COMMENTS

Page 11
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
Commercial Inland Marine
Client Name Pol No.
Policy
Effective Date
Expiration Date
Territory of Operation
Coverage / Deductible
Coverage
Perils
Deductible
Valuation
Coinsurance
Unscheduled Equipment
Description
Max per Item
Amount of Insurance (total)
Scheduled
Type / Description
ID or serial number
Manufacturer
Model
Year
Amount of Insurance
Additional Interest
Name / Address
Reference Number
Interest Type
ADDITIONAL COMMENTS
COMMENTS
 Umbrella-Excess
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy
Umbrella
Client Code: Pol no:
COV
COVERAGES
Umbrella or Excess
Claims Made or Occurrence
New or Renewal

Does the policy have the Punitive Damages

Exclusion listed in the policy?(Applicable to Yes/No
Allied/Nationwide Policies only)

LIMITS

Per occurrence
Aggregate
Other Limits
Other Limits Description
Retained Limit (Deductible)
Amount
UNDERLYING COVERAGES
Automobile
Carrier/ Policy #
Policy Period
Limits of Insurance
General Liability
Carrier/ Policy #
Policy Period
Limits of Insurance
Employers Liability
Carrier/ Policy #

Page 14
 Umbrella-Excess
Policy Period
Limits of Insurance
Abuse
Coverage
Carrier/ Policy #
Policy Period
Limits of Insurance
Professional Liability
Coverage
Carrier/ Policy #
Policy Period
Limits of Insurance
Employee Benefit Liability
Coverage
Carrier/ Policy #
Policy Period
Limits of Insurance
Workers Comp
Coverage
Carrier/ Policy #
Policy Period
Limits of Insurance
Other Policy
Coverage
Carrier/ Policy #
Policy Period
Limits of Insurance

UMBRELLA: Underlying coverages

information of policy document (carrier
name, coverages/limits, policy numbers,
policy term) should match with same
coverages which are in active.
(Matches/Does not Match)
Take the snaps of Dec pages/limits of same
coverages which are in underlying and
attach the snapshots in QA checkpoint sheet

Are underlying coverages serviced under

same Agency or Not? If Not say DOES NOT
MATCH
ADDITIONAL COMMENTS

Page 15
 Umbrella-Excess

Binder Expired Policy Status COMMENTS

Umbrella

If the policy has exclusion

of punitive damage then
say yes in Renewal/New
policy column and say
doesn't matches or/and if
the policy has inclusion of
punitive damage then say
No in Renewal/New policy
column and say Matches
If you find the form
number UMB0084 0310 in
Policy consider it as
included Punitive
Damages and show it as
Match

If limit less than $1M

please notify Respective
AM by showing DOESN'T
MATCH

Page 16
Umbrella-Excess

Page 17
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
Workers Compensation
Client Name: Pol No.
POLICY INFORMATION
Part 1 Workers Comp (States)
Part 2 Employers Liability Limits
Each Accident
Disease-Policy Limit
Disease - Each Employee
Are the Employer Liability Limits at the
required minimum limits?. Yes/No
If No please say DOESN'T MATCH and notify
AM through Summary
Part 3 Other States
LOCATIONS
Location #
Street
City State Zip
RATING INFORMATION
State
Class Code
Classification Description
Estimated Annual Remuneration
Rate
PREMIUM
Experience Modifier
INDIVIDUALS
Name
Included/Excluded
ADDITIONAL COMMENTS
COMMENTS
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
D&O and EPLI, E&O
Client Name: Pol No.
LOCATIONS
Address
REMARKS
Remarks
ERRORS AND OMISSIONS SECTION
Claims Made or Occurrence MATCHES
Retroactive date MATCHES
Combined Limits or Separate Limits MATCHES
Effective Date MATCHES
Expiration Date MATCHES
Defense Inside/Outside the Limit MATCHES
Duty to Defend - Insured or Company MATCHES
Pending Prior Litigation Date MATCHES
Extended Reporting Period(ERP) MATCHES
Cost for ERP On Policy MATCHES
LIMITS OF COVERAGE
Combined Limit Per Occurrence
Combined Aggregate
PRO Limit Per Occurrence
PRO Aggregate
EPLI Per Occurrence
EPLI Aggregate
DEDUCTIBLE/RETENTION
Combined Deductible or Retention
PRO Deductible or Retention
EPLI Deductible or Retention
ADDITIONAL COMMENTS
COMMENTS
 Accident Liability
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status COMMENTS
Accident Liability
Client Name: Pol no:
LOCATIONS
Locations
REMARKS
Remarks
LIMITS
Accident
DEDUCTIBLE
Deductible Amount
Deductible Basis
ADDITIONAL COMMENTS

Page 22
NAMED INSURED
POLICY NUMBER
WORK ORDER NUMBER
SECTION Sagitta Renewal Policy Binder Expired Policy Status
Commercial Crime
Client Name: Pol No.
Policy
Effective Date
Expiration Date
Estimated Premium
Issuing Company
LOCATIONS
Locations
COV
Blanket or Schedule
Employee Dishonesty / Theft
Blanket or Schedule
Limit
Deductible
ERISA
Plan Name
Total Asset Value
Limit
Deductible
Forgery or Alteration
Limit
Deductible
Theft of Money / Securities
Inside the Premises Limit
Deductible
Robbery / Burglary
Inside the Premises Limit
Deductible
Outside the Premises Limit
Deductible
Monies / Securities
Limit
Deductible
Computer Fraud
Limit
Deductible
ADDITIONAL COMMENTS
COMMENTS
SECTION Sagitta Renewal Policy Expired Policy Status COMMENTS
FORMS LIST
Are all Forms Attached?
Has a New Form Been Added to Policy this
year that was NOT on expiring Policy? If so,
list the form number.
Has a Form Edition Date Changed on
RENEWAL policy? If so, list.
Is a Form listed on EXPIRING Policy that is
NOT listed on the Renewal Policy? If so list.
ADDITIONAL COMMENTS