Please fill this out and a representative will contact you right away.

Name of Applicant

Address

City County State Zip              Business Phone Fax                   Email

If a policy is issued, it will be on a claims made basis.

1. Limits of Liability Desired:

$	each claim
$	aggregate for all claims

 

2. Deductible:
$2,500	$5,000	$10,000	$25,000	Other

 

3. Applicant is:
Individual	Partnership	Corporation	Non-Profit

 

4. Year Established: If less than two years, please provide resumes of all principals.

 

5. Please describe in detail the professional services for which coverage is sought.

 

6. Is the applicant engaged in any business or profession other than described in # 5?

No	Yes. If yes, please explain :

 

7. Please indicate the total annual gross revenues derived from the services described in # 5 for the past three years and the projected revenues for the current year:

 

Year	Revenue
a) Current
b)
c)

 

8. For the revenue listed in # 7a, please indicate the approximate percentage derived from each of the services listed in question # 5.

 

Service	Percentage of Revenue

 

9. Please indicate the number of:
a) Principals, partners, officers and professional employees directly engaged in providing services to clients:
b) All other non-professional/clerical emploees:

 

10. Does the applicant use a written contract with clients?

In all cases

Sometimes

Never

 

11. Has any professional liability insurance ever been declined or canceled?

No

Yes

 

12. Is any professional liability insurance currently in force?

No	Yes.	If yes, please indicate:
	Name of Insurer:
	Expiration Date:
	Limit of Liability:
	Deductible:
	Premium:
	Coverage in force since:

 

13. Does any director, officer, employee or partner of the applicant have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim?

No	Yes. If yes, please explain :

 

14. Has the applicant or any director, officer, employee or partner of the applicant ever been the subject of disciplinary action? Yes No If yes please explain.

No	Yes. If yes, please explain :

 

15. Please provide a list and status of all professional liability claims made during the past three years.

If none, please check here None