Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)
|
|
- Leslie Richardson
- 5 years ago
- Views:
Transcription
1 Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR TO CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE EXTENDED REPORTING PERIOD, IF APPLICABLE. THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES, SETTLEMENTS, OR JUDGMENTS SHALL BE REDUCED AND MAY BE EXHAUSTED BY DEFENSE EXPENSES, AND DEFENSE EXPENSES SHALL BE APPLIED AGAINST THE RETENTION. READ THE ENTIRE APPLICATION BEFORE SIGNING. 1. PLEASE PROVIDE CURRENT COPIES OF THE FOLLOWING: a) List of Employed Lawyers of the Company and its subsidiaries, including name, title and director/officer designation, year/jurisdiction of all bar admissions, and principal area of practice; b) List of all contract/leased attorneys used in the legal department of the Company and its subsidiaries, with a description of the practice areas in which these attorneys work; c) Company s Annual Report with most recent Audited Financials Statement, or the equivalent; d) Organizational charts of the legal department and of the Company with respect to its subsidiaries; and e) Legal department handbook or any written policies or procedures described in Question 4.i). 2. GENERAL INFORMATION a) Name of Company: (Wherever used, Company shall mean the entity applying for this insurance.) b) Address of principal office of the Company: City: State: ZIP: c) State of Incorporation: Years in business: Web site: d) Total number of employees in the Company: e) Current number of the following in the legal department of the Company and its subsidiaries: Employed Lawyers Paralegals, legal assistants and staff Contract/leased attorneys Law students/others f) Risk Manager or other individual designated as the representative to receive notices from the Underwriter on behalf of the Company and all individuals proposed for this insurance: Name: Title: address: Phone Number: 3. COMPANY INFORMATION NPA Page 1 of 8
2 a) Please provide a general description of the business of the Company: b) The Company is:! Publicly held! Privately held! For-profit! Non-profit c) Is the Company considering a public offering of debt or equity within the next eighteen (18) months? If Yes, please provide details. d) Does the Company have an indemnification policy or practice applicable to Employed Lawyers, regardless of whether those Employed Lawyers are directors or officers of the Company? 4. LEGAL DEPARTMENT INFORMATION a) Please check all areas which account for more than five percent (5 %) of the total work done by all Employed Lawyers of the Company and its subsidiaries and indicate the number of lawyers working in each area: Antitrust/Trade Regulation Collection/Repossession Contract Drafting/Review/ Approval Copyright/Patent/Trademark Corporate Finance Corporate Transactional Entertainment Environmental Law ERISA/Employee Benefits International Law Labor/Employment Litigation Mergers & Acquisitions Regulatory Compliance Pro Bono Real Estate Securities Taxation Trust & Estate Utility Regulation Other Other b) Does any Employed Lawyer issue written legal opinions to or for the use of: The Board of Directors: Subsidiaries or joint ventures: Third parties: Others: NPA Page 2 of 8
3 If Yes to any part of this question, please describe the types of opinions issued and the recipients thereof. c) Does any Employed Lawyer prepare, review, comment on, or approve financial statements, proxy statements, prospectuses, registration statements, annual or quarterly reports, or other reports filed with federal or state agencies or released to shareholders or the public regarding the Company and/or its subsidiaries? If Yes, please describe the role of Employed Lawyers in such preparation, review, comment or approval. d) Does any Employed Lawyer represent individual employees of the Company or its subsidiaries in judicial, administrative, or other proceedings? If Yes, please provide details. e) Does any Employed Lawyer provide personal legal services to any director, officer, or employee of the Company or its subsidiaries in such director s, officer s or employee s individual capacity? If Yes, please indicate the type of personal legal services provided and the percentage of the Employed Lawyer s time devoted to the provision of personal legal services: f) Does any Employed Lawyer provide moonlighting legal services to third party entities or to individuals who are not directors, officers or employees of the Company or its subsidiaries? If Yes, please indicate the type of moonlighting legal services provided and the percentage of the Employed Lawyer s time devoted to the provision of moonlighting legal services: g) Does any Employed Lawyer serve as a director, officer or partner of any organization, other than the Company, which is exempt from taxation under Section 501(c)(3) of the Internal Revenue Code? If Yes, please list the organizations served: NPA Page 3 of 8
4 h) Please provide a brief description of the structure and management of the legal department, including the legal department s placement within the general organization of the Company: i) With regard to the legal department, does the Company have written policies or procedures for the following: Training of newly hired Employed Lawyers? Continuing legal education for Employed Lawyers? Performance reviews for Employed Lawyers and staff? Circulation and updating of commonly used form documents? Litigation docket control? Preparation and approval of legal opinions? Compliance with the Sarbanes-Oxley Act of 2002? Handling internal investigations of employee complaints? If No to any of the above, please describe any relevant unwritten policies and procedures. j) Please indicate the types of legal work that are typically referred by the Company to outside counsel and any guidelines governing such referrals. 5. COMPANY S CURRENT SCHEDULE OF INSURANCE Employed Lawyers Professional Liability Directors & Officers Liability Limit Deductible Carrier Policy Term Premium Errors & Omissions (Professional) Liability 6. CLAIMS INFORMATION a) Has any Employed Lawyer ever been the subject of a reprimand, sanction, fine or discipline by, or been refused admission to, a bar association, court, the U.S. Securities and Exchange Commission or any administrative agency? NPA Page 4 of 8
5 If Yes, please provide the name of the Employed Lawyer and a brief explanation. NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM ARISING FROM ANY REPRIMAND, SANCTION, FINE, DISCIPLINE OR ADMISSION REFUSAL REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.a) IS EXCLUDED FROM THE PROPOSED INSURANCE. b) During the past five (5) years, has any claim or suit been made against any Employed Lawyer arising out of his or her provision of legal services, whether or not such claims or suits arose out of work performed for the Company or its subsidiaries? If Yes, please complete a Claim Summary Supplement for each such claim or suit. NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM OR SUIT REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.b) IS EXCLUDED FROM THE PROPOSED INSURANCE. c) Is any Employed Lawyer aware of any fact, circumstance, situation, transaction, event, act, error or omission which he or she has reason to believe may or could reasonably be foreseen to give rise to a claim against any Employed Lawyer in his or her capacity as an attorney, director or officer of the Company or its subsidiaries? If Yes, please complete a Claim Summary Supplement for each such fact, circumstance, situation, transaction, event, act, error or omission. NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM ARISING FROM ANY FACT, CIRCUMSTANCE, SITUATION, TRANSACTION, EVENT, ACT, ERROR OR OMISSION REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.c) IS EXCLUDED FROM THE PROPOSED INSURANCE. 7. SIGNATURES AND AUTHORIZATIONS The undersigned, as authorized agent of the Company, its subsidiaries and all individuals proposed for this insurance, declares that, to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this Application and any attachments of information submitted with this Application (together referred to as the Application ) are true and complete. The information in this Application is material to the risk accepted by the Underwriter. If a policy is issued it will be in reliance by the Underwriter upon the Application, and the Application will be the basis of the contract. NPA Page 5 of 8
6 The information contained in and submitted with this Application is on file with the Underwriter and, along with the Application will be considered physically attached to, part of, and incorporated into the policy, if issued. The Underwriter is authorized to make any inquiry in connection with this Application. The Underwriter s acceptance of this Application or the making of any subsequent inquiry does not bind the Company or the Underwriter to complete the insurance or issue a policy. If the information in this Application materially changes prior to the effective date of the policy, the Company will immediately notify the Underwriter, and the Underwriter may modify or withdraw any quotation or agreement to bind insurance. The undersigned declares that the Company and all individuals proposed for this insurance understand: a) the policy, if issued, shall apply only to Claims that are first made against the Insured during the Policy Period or the Extended Reporting Period, if applicable; and b) the limit of liability available under the policy, if issued, to pay damages, settlements, or judgments shall be reduced, and may be exhausted, by payment of Defense Expenses, and Defense Expenses also shall be applied against the retention. FRAUD WARNINGS NOTICE TO ALABAMA AND MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO ARKANSAS, MINNESOTA, AND OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING - it is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NPA Page 6 of 8
7 NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. NOTICE TO LOUISIANA, NEW MEXICO AND RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO OREGON AND TEXAS APPLICANTS: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. COMPANY: BY (General Counsel, CEO, CFO or Risk Manager of the Company): TITLE: DATE: Notice: This Application must be signed by the General Counsel, CEO, CFO or Risk Manager of the Company acting as the authorized agent of the Company, its subsidiaries and all individuals proposed for this insurance. NPA Page 7 of 8
8 PRODUCED BY (Insurance Agent) INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. INSURANCE AGENCY AGENT LICENSE NO. ADDRESS (No., Street, City, State, and ZIP Code) SUBMITTED BY (Insurance Agency) INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. AGENT LICENSE NO. ADDRESS (No., Street, City, State, and ZIP Code) NPA Page 8 of 8
APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE
Executive Risk Management Associates 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED
Employed Lawyers Professional Liability Application
Employed Lawyers Professional Liability Application THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED INSURANCE. NOTICE: THE LIMIT OF LIABILITY AVAILABE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED
ACE Advantage. Employed Lawyers Professional Liability Application
ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Employed Lawyers Professional Liability Application
Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)
Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYMENT PRACTICES LIABLITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION
Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group)
Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) NETWORK SECURITY AND PRIVACY LIABILITY RENEWAL APPLICATION PORTIONS
APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE
Monroe Insurance Brokerage, Inc. Home Office M o n t e r e y, C a l i f o r n i a 9 3 9 4 0 APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION
NON PROFIT MANAGEMENT LIABILITY APPLICATION
NON PROFIT MANAGEMENT LIABILITY APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED REPORTING
OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application
OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application NOTICE: This is an application for a claims-made and reported policy. Subject to its terms, this policy
SAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION
Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 Executive Risk Indemnity Inc. 2711 Centerville Road Suite 400, Wilmington, Delaware 19808 SAFETY NET SHORT FORM INTERNET
APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE
APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY
BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER )
BY COMPLETING THIS YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY
DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION
DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION RSUI Indemnity Company Landmark American Insurance Company NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO
LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THE POLICY APPLIES
ERRORS & OMISSIONS INSURANCE APPLICATION
ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: Indian Harbor Insurance Company 505 Eagleview Blvd. Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 THIS IS AN APPLICATION
National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION
National Union Fire Insurance Company of Pittsburgh, Pa. (herein called the Insurer ) LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION NOTICE THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS
Executive Risk Indemnity Inc.
Executive Risk Indemnity Inc. Home Office: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR MANAGEMENT LIABILITY INSURANCE FOR PROFESSIONAL FIRMS NOTICE: THE POLICY FOR WHICH APPLICATION
Hudson Insurance Company 100 William Street, New York, NY 10038
Hudson Insurance Company 100 William Street, New York, NY 10038 APPLICATION FOR DIRECTORS & OFFICERS INSURANCE POLICY COMPLETION OF THIS APPLICATION DOES NOT COMMIT OR BIND THE UNDERSIGNED TO PURCHASE
RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
Executive Risk Indemnity Home Office Wilmington, Delaware 19808 Administrative Offices/Mailing 82 Hopmeadow Simsbury, Connecticut RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE NOTICE:
6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:
Name of Insurance Company to which Application is made (herein called the Insurer ) CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR DEFENSE COSTS, ADMINISTRATIVE EXPENSES, NOTIFICATION COSTS,
Executive Protection Portfolio SM Fiduciary Liability Coverage Application
BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. (THE COMPANY ) NOTICE: THE FIDUCIARY LIABILITY COVERAGE SECTION OF THIS POLICY PROVIDES CLAIMS MADE COVERAGE,
PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION
BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: READ THE ENTIRE CAREFULLY BEFORE SIGNING. INSTRUCTIONS: 1. Whenever used in this Pension
UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY A. GENERAL INFORMATION
Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 APPLICATION VENTURE CAPITAL ASSET PROTECTION POLICY UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY
ERRORS & OMISSIONS INSURANCE APPLICATION
ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
PART I. TELL US WHO YOU ARE
Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) One Beacon Lane Canton, MA 02021 HEALTH CARE CONSULTANT PROFESSIONAL
LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION
DARWIN NATIONAL ASSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. (860) 284-1300 Fax (860) 284-1301 LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY
BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY )
.. BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: INSURING CLAUSE A OF THE POLICY PROVIDES CLAIMS MADE COVERAGE, WHICH APPLIES ONLY TO "CLAIMS"
BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY )
BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) NOTICE: PLEASE ANSWER ALL OF THE FOLLOWING INQUIRIES.
SmartPro Property Managers E&O Application
NOTICE: THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE AND REPORTED IN WRITING DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTING PERIOD. THE LIMIT
APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION
APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY Instructions for Completing This Application Please read carefully and fully answer all questions and submit all requested information
MULTIMEDIA SM LIABILITY Application for Advertising Agencies
BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. ( Insurer ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY
ERRORS & OMISSIONS RENEWAL APPLICATION
ERRORS & OMISSIONS RENEWAL APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY NETWORK SECURITY SUPPLEMENTAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY, WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO CLAIMS WHICH ARE BOTH FIRST MADE
TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477
TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE TO ALL APPLICANTS:
ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS
ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS 1. Name and Address of Applicant: (Please include DBA s/subsidiaries, etc.)
TORUS NATIONAL INSURANCE COMPANY MANAGEMENT LIABILITY APPLICATION FOR PRIVATE COMPANIES (NON-FINANCIAL INSTITUTIONS)
TORUS NATIONAL INSURANCE COMPANY MANAGEMENT LIABILITY APPLICATION FOR PRIVATE COMPANIES (NON-FINANCIAL INSTITUTIONS) THIS APPLICATION APPLIES TO MANY COVERAGE PARTS. ACCORDINGLY, IT IS ONLY NECESSARY TO
APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR ACCOUNTANTS PROFESSIONAL
Eidyia Insurance Services
Eidyia Insurance Services MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE: THE LIMIT OF LIABILITY AVAILABLE TO
Miscellaneous Professional Liability Application
Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY GENERAL LIABILITY SUPPLEMENTAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE
1. a) Name of Applicant: (Whenever used in this Application, the term "Applicant" shall mean the Parent Corporation and all Subsidiaries.
Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR DIVERSIFIED HEALTHCARE
EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE
Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations
Northwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com
APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE
APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THE POLICY FOR WHICH THIS APPLICATION IS MADE IS LIMITED TO LIABILITY FOR
RENEWAL Application for Business and Management (BAM) Indemnity Insurance
rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com
LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION
ASPEN AMERICAN INSURANCE COMPANY LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION NOTICE: This is an application for a claims-made and reported policy. Coverage for prior acts and claims made after
EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE
Application For Business and Management (BAM) Indemnity Insurance
Application For Business and Management (BAM) Indemnity Insurance NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM OR LOSS DISCOVERED (AS APPLICABLE IN
TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE APPLICATION
REGULATORY OFFICE 505 Eagleview Blvd., Ste. 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE APPLICATION THIS IS A CLAIMS
THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION
Name of Insurance Company to which Application is made THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION This is an application for a CLAIMS-MADE AND REPORTED Policy If a policy is
Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110
Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE
DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION
DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY APPLIES
EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION NOTICES: THE EMPLOYMENT PRACTICES LIABILITY COVERAGE PART/ENDORSEMENT PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR
1. Provide the following information on personnel for which you have responded Yes to either question 23b. or 23c.: Professional Designations Earned
Hanover Professional Portfolio Accountants Professional Liability Insurance Financial Planning & Investment Advisory Services Supplement Underwritten by The Hanover Insurance Company THIS POLICY PROVIDES
INSTRUCTIONS FOR COMPLETING THIS APPLICATION
MAIN FORM APPLICATION FOR PRIVATE COMPANY DIRECTORS AND OFFICERS AND CORPORATE LIABILITY INCLUDING EMPLOYMENT PRACTICES LIABILITY INSURANCE ( PRIVATE PLUS ) Name of Insurance Company to which this Application
BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION
BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION NOTICE: INSURING AGREEMENTS I.A., I.C., I.D. AND I.F. OF THIS POLICY PROVIDE COVERAGE
Berkley Insurance Company
Lawyers Professional Liability Insurance New Business Application CLAIMS MADE WARNING FOR APPLICATION: This Application is for a Claims Made and Reported Policy, relating to claims made against the Insureds
PROFESSIONAL LIABILITY INSURANCE ADD LAWYER INFORMATION SUPPLEMENT
PROFESSIONAL LIABILITY INSURANCE ADD LAWYER INFORMATION SUPPLEMENT Medmarc Casualty Insurance Company 14280 Park Meadow Drive Suite 300 Chantilly, VA 20151-2219 800.356.6886 703.652.1300 1. New Lawyer:
AIG CORPORATE IDENTITY PROTECTION
Name of Insurance Company To Which Application is Made Name of Insurance Company to which Application is made (herein called the Insurer ) AIG CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR
APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE
APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE
Chubb Custom Market Recreational Marine Piers, Wharves & Docks Application
BY COMPLETING THIS Piers, Wharves & Docks APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH Chubb Group of Insurance Companies (THE COMPANY ) Piers, Wharves & Docks APPLICATION INSTRUCTIONS: 1. Whenever
ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL INSURANCE APPLICATION
ALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319 ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL
Kidnap Ransom & Extortion Coverage Iraq and Pakistan Supplemental Application
BY COMPLETING THIS KIDNAP RANSOM & EXTORTION COVERAGE (KR&E) FOR IRAQ AND PAKISTAN SUPPLEMENTAL APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE:
Title Agents Professional Liability Application
1. Name of Applicant Address Phone Number Fax Number E-mail Address 2. Are there other office locations? Yes No If yes, please list (include county): 3. Applicant is: Sole Proprietor Partnership Corporation
MISSOURI - THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY
, a stock insurance company, herein called the Insurer MISSOURI - THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY AGENCY NAME: HARTFORD
ALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319
ALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319 ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY INSURANCE
RENEWAL Application for Business and Management (BAM) Indemnity Insurance
rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com
Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110
Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE
SECURITIES SUPPLEMENT
SECURITIES SUPPLEMENT Name of Applicant Firm: _ Attorneys 1. For each attorney of the Applicant Firm handling Securities matters, please provide the following information: Attorney Name Securities Billable
ACE American Insurance Company
Named Applicant: Date: ACE American Insurance Company ACE Advantage ACE American Insurance Company National Association of REALTORS Professional Liability Name of insurance company to which Application
Crime Social Engineering Fraud Supplemental Application
BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: THE COVERAGE AFFORDED UNDER THIS COVERAGE SECTION DIFFERS IN SOME RESPECTS FROM THAT AFFORDED
MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT
Specified Professions Professional Liability Product
Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy carefully. SECTION I: BACKGROUND
Application for Fire & Water Restoration Contractors
Application for Fire & Water Restoration Contractors Please complete the application in its entirety. Instructions Note: Completion of this application does not bind coverage. The applicant s acceptance
Lawyers Professional Liability Application
Lawyers Professional Liability Application NOTICE: This is an application for a claims made and reported policy. This policy covers only claims first made and reported during the policy period or extended
Bookkeepers Professional Liability Insurance
Bookkeepers Professional Liability Insurance To obtain Professional Liability Insurance through North American Professional Liability Insurance Agency, LLC complete the information below, along with the
Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE
Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE FL- 024 DOFIRST NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED
APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS
Name of Insurance Company to which application is made APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS NOTICE: THE LIABILITY COVERAGE PARTS SCHEDULED IN ITEM 5 OF THE DECLARATIONS
EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION
595 STEWART AVE GARDEN CITY, NEW YORK 11530-4735 P 516-745-1111 F 516-745-5733 SOBELINS.COM EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS SUBMITTED
Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION
Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an
ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION
ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION NOTICE: THE LIABILITY COVERAGE PARTS OF THIS POLICY PROVIDE CLAIMS MADE COVERAGE. EXCEPT AS OTHERWISE PROVIDED, SUCH COVERAGE APPLIES ONLY
Part 1: APPLICANT INFORMATION
AMERICAN ACADEMY OF STATE CERTIFIED APPRAISERS A RISK PURCHASING GROUP REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY APPLICATION NEW BUSINESS NOTE: This is an application for a Claims Made policy. Coverage
HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION
HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION Please note: This application is intended to be used for HVAC contractors with under $1,000,000 in receipts. On accounts
GENERAL LIABILITY SUPPLEMENTAL APPLICATION
AFB MEDIA TECH PROFESSIONAL AND TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING LIABILITY INSURANCE POLICY GENERAL LIABILITY SUPPLEMENTAL APPLICATION
THE HARTFORD CRIMESHIELD ADVANCED RENEWAL APPLICATION FOR NON CUSTODIAL REGISTERED INVESTMENT ADVISORS (1 st Party Coverage)
< >, a stock insurance company, herein called the Insurer THE HARTFORD CRIMESHIELD ADVANCED RENEWAL APPLICATION FOR NON CUSTODIAL REGISTERED INVESTMENT ADVISORS (1 st Party Coverage) Agency Name: Hartford
GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application
GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application NOTICE: This is an application for a Claims-Made policy. Coverage for prior acts and claims made after termination
ERRORS AND OMISSIONS INSURANCE APPLICATION COLLECTION AGENTS ERRORS AND OMISSIONS
ERRORS AND OMISSIONS INSURANCE APPLICATION COLLECTION AGENTS ERRORS AND OMISSIONS 1. Applicant Name: Address: 2. a. What type(s) of collections are handled? b. What is the average dollar value of each
THE HARTFORD PROFESSIONAL LIABILITY POLICY CONSULTANTS INSURANCE APPLICATION
Name of Insurance Company to which Application is made THE HARTFORD PROFESSIONAL LIABILITY POLICY CONSULTANTS INSURANCE APPLICATION This is an application for a CLAIMS-MADE AND REPORTED Policy If a policy
LAWYERS PROFESSIONAL LIABILITY
NAVIGATORS INSURANCE COMPANY (NAV) NAVIGATORS SPECIALTY INSURANCE COMPANY (NSIC) LAWYERS PROFESSIONAL LIABILITY NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims
PROPOSAL FOR DIVERSIFIED BUSINESS ORGANIZATION AND MANAGEMENT LIABILITY INSURANCE
U.S. SPECIALTY INSURANCE COMPANY HOUSTON CASUALTY COMPANY 13403 Northwest Freeway Houston, Texas 77040 PROPOSAL FOR DIVERSIFIED BUSINESS ORGANIZATION AND MANAGEMENT LIABILITY INSURANCE NOTICE: THIS IS
Most Recent FYE (Month/Year) ( / ) Current Assets $ $ Total Assets $ $
Travelers Excess and Surplus Lines Company Wrap Employment Practices Liability Renewal Coverage Application The term Applicant means all corporations, organizations or other entities, including subsidiaries,
Clergy Counseling Errors and Omissions Application
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
COURT REPORTERS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY
United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,
NAVIGATORS INSURANCE COMPANY Real Estate Professional Errors and Omissions Insurance EXPRESS APPLICATION - Missouri
NAVIGATORS INSURANCE COMPANY Real Estate Professional Errors and Omissions Insurance EXPRESS APPLICATION - Missouri To be eligible for this express application you must be able to answer "true" to statements
Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application
Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after
Credit Insurance Application
Credit Insurance Application 1. General Information Name of Applicant Address City State Zip Phone Fax Email Representative and title of person designated to receive all notices concerning this insurance:
CONSULTANTS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY
United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,
Malpractice Insurance For International Board Certified Lactation Consultants
Malpractice Insurance For International Board Certified Lactation Consultants 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions
Application For ACE EXPRESS Non Profit Organization Management Indemnity Package
Application For ACE EXPRESS n Profit Organization Management Indemnity Package NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM MADE AGAINST ANY OF THE
LAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION Medmarc Casualty Insurance Company 14280 Park Meadow Drive Suite 300 Chantilly, VA 20151-2219 800.356.6886 703.652.1300 NOTICE: This professional