Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@zolofrainsurance.com





Name (as it should appear on the policy)

Name of Organization

Street Address

City

County

State

Zip Code

Email

Phone Number

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)

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?


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

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.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.

After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!

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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@zolofrainsurance.com
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