Miscellaneous Professional Liability Online Insurance Application

Name

Name of Organization

Street Address

City

County

State

Zip Code

Email

Phone Number

What type of business formation is the applicant?


Please Select Corporation Partnership LLC Individual

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.


Please Select Yes No

Are you engaged in any business or profession other than as described above?


Please Select Yes No

If yes, please provide details and estimated annual revenues for the other engagement(s):

# of principals / partners

# of Employees (excluding principals and partners)

Full Time:


Part Time:

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?


Please Select Yes No

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


Please Select Always Sometimes Never

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 Select Yes No

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.


Please Select Yes No

Do you currently have Professional Liability (E&O) coverage?


Please Select Yes No

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.


Please Select Yes No

What limit of E&O liability is desired for the next policy period?


 $250,000
 $500,000
 $1,000,000
 $2,000,000
 Other

Additonal Comments:

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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