Name (as it should appear on the policy)
Name of Organization
What type of business formation is the applicant?
Please describe in detail the professional activities for which coverage is desired
How many years experience do you have in this profession?
What year was this business established
Is the applicant firm controlled, owned, or associated with any other firm, corporation or company? If yes, please explain in the comments section at the end of this form.
Are you engaged in any business or profession other than as described above?
If yes, please provide details and estimated annual revenues for the other engagement(s):
# of principals / partners
# of Employees (excluding principals and partners)
Have any principal, partner. or associate of the firm ever been the subject of disciplinary action by authorities as a result of their professional activities?
To what professional associations does the applicant firm belong to?
Projected Annual Revenue
Prior Year Annual Revenue
Prior Revenue, Two Years Ago
Please provide a list of the firm’s five (5) largest jobs or projects during the past three (3) years. Please provide in detail:
1. Project/client name, 2. Nature of the services provided for the client, and 3. the revenues from those services.
Does the firm use a written contract with the client
What percentage of the firm’s projected gross revenue involves subcontracting of work to others?
Does the firm provide professional services to business entities in which it retains an ownership interest? If yes, please explain in the comments section below prior to submitting.
Please provide percentages for your area of practice. (all parts to total 100%)
Has any similar insurance ever been declined or cancelled? If yes, please explain in the comments section prior to submitting.
Do you currently have Professional Liability (E&O) coverage?
Policy expiration date:
Who is your current E&O carrier?
What are your current E&O limits?
What is your current E&O deductible?
Retro Date on current E&O policy (mm/dd/yyyy)
What is the expiring annual premium?
# of claims in the last 5 years
Claim Details (Provide date of claim, amount paid by insurer and circumstances)
Does any person to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim against him/her? If yes, please explain in the comments section below prior to submitting.
What limit of E&O liability is desired for the next policy period?
$250,000 $500,000 $1,000,000 $2,000,000 Other
Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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Name Of Your Company or type of business if seeking commercial insurance (required)
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