261 Gerrard St. East Toronto, ON M5A 2G1 P: F: Professional Liability Insurance for Personal Support Workers!
|
|
- Leona Norris
- 8 years ago
- Views:
Transcription
1 261 Gerrard St. East Toronto, ON M5A 2G1 P: F: September 17, 2015 Professional Liability Insurance for Personal Support Workers! Dear Sister/Brother, This year we have partnered with the insurance brokerage LMS PROLINK to manage the Professional Liability Insurance program for PSW s who are members of CUPE. We urge you to protect their valuable careers and obtain an insurance policy with LMS PROLINK. It is important to protect their own career and to not relying solely on your employer s policy which is designed to protect your employer. One of the main benefits of obtaining your own professional liability insurance is for when a claim arises; you will be assigned your OWN legal counsel whose priority is to represent YOUR interests. Your employer s policy is designed to protect your employer. If you are named in a suit, you would not have to share legal resources with your employer when you maintained your own professional liability policy. PSW s are trusted with the lives of the people they support. Any mistake could result in injury or loss of life. This is why OCHU is eager to launch a new Professional Liability Program for Personal Support Workers (PSW) and Developmental Service Workers (DSW) who are members of CUPE. Coverage starts as early as October 15, HIGHLIGHTS INCLUDE: ü Members can obtain $1,000,000 in Professional Liability Protection for a total annual cost of $115+ tax. Higher Limits are also available up to $2,000,0000 ($150 + tax). All with no deductible! ü Complete online solutions Apply, pay and obtain your certificate of insurance in less than 5 minutes! ü Limited Coverage extended to PSW services rendered outside of your employment agreement with a hospital, long-term care facility, nursing home or retirement home.
2 ü ü Members do not have to pay fees to a separate PSW Association in order to access competitive group insurance rates! Limited coverage for reimbursement for lawyers fees incurred if PSW is successful for defence against criminal charges or claims of Abuse We urge you communicate this preliminary information to you fellow CUPE PSW Sisters and Brothers. Your support is crucial in the success of this insurance program. Please contact LMS PROLINK at ext if you have further questions. Yours in solidarity, Helen Fetterly, Secretary-Treasurer The Canadian Union of Public Employees (CUPE) has represented PSWs since The Ontario Council of Hospital Unions (OCHU) was established in 1982 to bring together CUPE hospital locals in a democratic structure with one major objective to bargain with participating hospitals on central issues. Today, the membership of the Ontario Council of Hospital Unions (OCHU) includes 30,000 CUPE hospital, long-term care, ambulance and central laundry workers in 120 bargaining units across Ontario.
3 PSW Professional Liability Insurance A Price Comparison Brought to you by: LMS PROLINK Ltd. There are many insurance brokers in Ontario that can provide Professional Liability quotes for PSW s. The most cost effective quotes would come from a group plan from an Association or Union. We understand that any extra cost to practice as a PSW can be an issue for CUPE members. The cost to protect you as a PSW is basically less than $2.50 per week. To make sure the cost of $115 per year is competitive we have included pricing from other PSW Insurance programs currently advertised. 1. Ontario Personal Support Worker Association (OPSWA) Highlights of Advertised Coverage: Total Annual Cost: Please see below for analysis of PSW Insurance in the marketplace: $2,000,000 per Claim Limits $500,000 Abuse Liability Defence $15,000 Personal Accident, Death and Disability $307+ tax ($162 + $25 fee + $120 OPSWA fee) 2. Lloyds of London Insurance Program for Canadian Therapy Professionals Highlights of Advertised Coverage: Total Annual Cost: $180 + tax $1,000,000 per claim limits Established in 1982, LMS PROLINK Ltd. is a 100% Canadian owned Insurance Brokerage. With our subsidiary UnionLINK Insurance Brokers Inc. we manage over 40 group insurance programs for members of associations and labour unions. Please contact LMS PROLINK Ltd. at ext if you have further questions or visit them online at
4
5 OCHU/CUPE Professional Liability Insurance Program FAQs When does the OCHU/CUPE Professional Liability Protection Program for PSW/DSW s start? The starting date of coverage is October 15, I have not received the information package from CUPE and want to apply for the coverage. I also need a user name and password to apply online. Who can I contact? Please OCHUPSW@LMS.ca or call ext What are the requirements to qualify for this program? You must be a Personal Support Worker (PSW) or Developmental Support Worker (DSW) and be a CUPE Union Member in good standing. What is Professional Liability Protection? Professional Liability Protection (PLP) is also known as Professional Liability Insurance, Malpractice or Errors & Omissions Insurance. In the event a third party (i.e. patient) makes a claim against you arising out your professional service as a PSW/DSW, the policy will respond to liability from negligence while rendering, or failure to render, professional service. Professional Liability insurance provides claims assistance and legal representation. The limit of insurance purchased covers both legal defense costs and damages awarded to a third party. The Professional Liability Protection starts at $1,000,000 in coverage. What will $1,000,000 pay for? We have all heard media reports of professionals or organizations being sued for damages to a victimized third party. Damages are typically only one part of the claim that would be paid out by an insurance policy. The majority of all claims paid out by a Professional Liability Policy are to cover the fees and legal expenses required to mount a legal defence. In most cases, damages are not even awarded to a victim, but lawyers will still require compensation. Currently the average fee for a lawyer who specialized in medical malpractice insurance in Canada is $500 $700 per hour. The liability limit will pay for all reasonable and necessary costs, charges, fees, (including but not limited to legal fees) and expenses incurred over the course of an investigation, negotiation, arbitration and defence of any covered claim.
6 I am solely an employee. Would my employer s insurance policy not protect me? As a health care professional, relying on your employers insurance is risky. Should you be named in a lawsuit, your employer and yourself will be named in the lawsuit. Your employer s liability policy is designed to protect your employer, not you. Benefits of maintaining your own policy and not replying on your employer s policy include: The limit of insurance on your employer s policy will be shared by you, your employer, or anyone else named in a suit. If the judgment against you is higher than your employer s limit of insurance, you could be responsible for your share of the excess amount. When you have your own policy, during a lawsuit, you will be assigned your own legal counsel and defence. You will not have to share legal resources with your employer s lawyer. You are most likely not aware if your employer is keeping their insurance up to date. If their policy is cancelled or lapsed you will not have coverage for yourself. Do you conduct PSW/DSW services outside your employment agreement? Your employer s policy surely would not cover your other activities. If your employer decided that you acted outside the scope of your agreement their policy may not protect you. What happens if I change jobs, work for more than one employer, volunteer elsewhere, work for my own private practice, or assist a stranger in public? As long as you are a member of CUPE, coverage will extend to your other PSW/DSW related employment, volunteer or Good Samaritan activities. If you work independently/privately (ie. providing services in the home of a private individual client) there are limitations and conditions to the policy: - You will be covered for up to $100,000 with a maximum of $250,000 to be paid for all private claims on the OCHU program - You must not be contravening your employment / union agreement - You must be providing these services on a part-time basis only no more than 15 hours per week - $1,000 deductible for claims brought forth as a result of your non-cupe private work. Is there a deductible? As mentioned above there is a $1,000 deductible for claims from your non-cupe private/independent services. There is no deductible for all other claims Am I covered if a patient accuses me of abuse? - Criminal acts such as molestation, harassment, corporal punishment, assault or battery or any form of sexual or physical abuse are not covered under this Professional Liability Protection policy. If however you are successfully acquitted and receive a not guilty verdict (or the charges are withdrawn) this policy will reimburse you up to $25,000 for legal expenses incurred to defend you subject to a maximum of $250,000 to be paid for all Abuse claims on the OCHU program. When I take out insurance through LMS PROLINK, is this for an annual term? All policies under the OCHU/CUPE program will expire October 15 regardless of when you apply. We will you in August to remind you to renew your insurance. I applied and paid online. Should I have received confirmation in the mail? No. You would have received your credit card confirmation / receipt via . To view and print your evidence of insurance, go directly to Your user name will be your complete address, and your new password was created by you during the online application process. For more information please visit If you still have questions and would like to speak to an insurance professional, please contact LMS PROLINK directly at OCHUPSW@LMS.ca or at by calling our office toll free at during regular business hours (M-F, 8am to 5pm EST).
7 OCHU/CUPE Professional Liability Insurance Instructions for PSW s To apply for liability insurance or to view plan pricing / coverage please follow these simple instructions: 1. Go to 2. Click on the APPLY ONLINE tab in the left section of the webpage. 3. If logging in for the very first time use the following generic credentials: a. User Name: ochupsw b. Password: ochu12 4. This will get you into the online application. Set up your own account by entering your CUPE local number and complete the application. You will also be prompted to set up a unique account using your own as the user name and your own password. This will be the credentials you use from now on to log back into the system. 5. If you pay with Visa / MasterCard (and there are no issues with your application) you will be able to bind coverage immediately and sign back in to obtain your proof of insurance. Simply log back in by following steps 1 & 2. Your complete address is now your User Name and you created your unique Password while applying online. A credit card receipt will also be automatically ed to you. If you opt not to use credit card, than you will be ed once your application has been manually approved and payment method has been cleared. If these instructions are unclear, or if you require more information please contact LMS PROLINK directly at OCHUPSW@LMS.ca or at by calling our office toll free at during regular business hours (M-F, 8am to 5pm EST).
8
9 PERSONAL SUPPORT WORKER AND DEVELOPMENTAL SUPPORT WORKER MEMBERS OF THE ONTARIO COUNCIL OF HOSPITAL UNIONS/CANADIAN UNION OF PUBLIC EMPLOYEES PROFESSIONAL LIABILITY INSURANCE APPLICATION Please forward application to: LMS Prolink Ltd. 480 University Avenue, Suite 800 Toronto, Ontario M5G 1V2 Tel: Fax: (a) Applicant s Full Name: (b) Mailing Address: (c) Address: (d) Telephone: 2. (a) CUPE Local No.: (b) Are you a CUPE member in good standing? Yes No Note: only members in good standing with CUPE are eligible to purchase coverage under this insurance program. 3. (a) Confirm your occupation: Personal Support Worker (PSW) Developmental Support Worker (DSW) (b) Confirm the name of the college you attended: (c) Confirm the length of the course: 500 hours 600 hours Other: (d) Confirm the year that you graduated: 4. Confirm whether you are: solely an employed professional (Provide employer s name: ) an employed professional, but also working part-time as an independent practitioner or in private practice 5. Confirm the areas where you work: Hospital Retirement Home Long-term Care Home Nursing Home Community Health Centre Family Health Team Clinic Patient s Residence Other: 6. Select one of the Professional Liability options below: Limits of Liability Deductible *Annual Premium 8% P.S.T. Total Amount Due $1,000,000 per claim / $1,000,000 aggregate $0 $ $8.80 $ $2,000,000 per claim / $2,000,000 aggregate $0 $ $11.60 $ All Annual Premiums include a $5.00 Administration Fee If you answer Yes to any of the following questions, you must remit full details to LMS Prolink Ltd. 7. Have you ever been declined, non-renewed or cancelled by an insurer for Professional Liability Insurance? Yes No If Yes, explain: 141.ManAppe (09/15) Trisura Guarantee Insurance Company Page 1 of 2
10 8. Have you ever been subject to disciplinary action by, or suspended from practice by, any governing body ofyour profession? Yes No If Yes, explain: 9. Have you ever had a claim made against you arising out of the performance of professional services? Yes No If Yes, please provide the following details on a separate sheet: (a) Date of Claim; (b) Claimant s Name; (c) Nature of Claim; (d) Current Status of Claim; THE APPLICANT DOES HEREBY PROVIDE THE FOLLOWING WARRANTY TO THE INSURER 10. Do you have knowledge or information of any fact, circumstance or situation which could reasonably give rise to a claim which would fall within the scope of the proposed insurance? Yes No If Yes, provide details: It is understood and agreed that if knowledge of any such facts, circumstances or situations exists, whether or not disclosed, any claim or action subsequently arising or developing therefrom shall be excluded from coverage under any policy issued by Trisura Guarantee Insurance Company. PRIVACY DISCLOSURE AND CONSENT The undersigned authorized representative acknowledges that any personal information provided in connection with the insurance applied for, including but not limited to the information contained in this Application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of any investigation and inquiry in connection with this Application for insurance and, if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law. FALSE INFORMATION 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 information concerning any fact material thereto for the purpose of misleading any insurance company or other person, commits a fraudulent insurance act which is a crime. DECLARATIONS AND SIGNATURE The undersigned authorized representative of the Applicant: (i) declares, after inquiry, that the statements and representations set forth in this Application, and all materials submitted to or requested by the Insurer in conjunction with this Application, are true; (ii) acknowledges that these statements, representations, and materials are relied on by the Insurer and that they shall be deemed material to the acceptance of the risk assumed by the Insurer under the insurance applied for, should the insurance be effected; and (iii) agrees that if the information supplied in connection with this Application changes between the date of this Application and the effective date of any insurance effected pursuant to this Application, the undersigned will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding indications, quotations and/or authorization or agreement to effect the insurance. Signing of this Application does not obligate the Applicant or the Insurer to effect the insurance, but it is agreed that all materials submitted to or requested by the Insurer in conjunction with this Application are hereby incorporated by reference into this Application and made a part hereof. It is further agreed that this Application and all materials submitted to or requested by the Insurer in conjunction with this Application are the basis of and are deemed attached to and incorporated into any policy effected pursuant to this Application. PLEASE NOTE: COVERAGE CANNOT BE EFFECTED UNTIL THIS APPLICATION HAS BEEN FULLY COMPLETED, DULY SIGNED AND DATED, AND THE PREMIUM HAS BEEN PAID IN FULL. Signature Date 141.ManAppe (09/15) Trisura Guarantee Insurance Company Page 2 of 2
205 Richmond St. West, Suite 502 Toronto, ON M5V 1V3 P: 416-599-0770 F: 416-599-3982
205 Richmond St. West, Suite 502 Toronto, ON M5V 1V3 P: 416-599-0770 F: 416-599-3982 February 11, 2014 Dear Member, As an RPN registered in Ontario, you have probably received information from the College
More informationStarting date of coverage is March 31, 2014
Ontario Council of Hospital Unions / CUPE has partnered with LMS PROLINK to provide Professional Liability Protection (PLP) exclusively for Registered Nurses who are members of CUPE. For over 30 years
More informationSOCIAL WORKERS PROFESSIONAL LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE POLICY APPLICATION FOR THE OASW
SOCIAL WORKERS PROFESSIONAL LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE POLICY APPLICATION FOR THE OASW Application SECTION 1: GENERAL INFORMATION YOU MUST BE A MEMBER IN GOOD STANDING WITH THE
More informationMISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE POLICY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE POLICY APPLICATION THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY WITH CLAIM EXPENSES INCLUDED IN THE LIMIT OF LIABILITY. All questions must be answered
More informationDIRECTORS AND OFFICERS LIABILITY INSURANCE INCLUDING CORPORATE INDEMNITY POLICY APPLICATION PROFIT CORPORATIONS
DIRECTORS AND OFFICERS LIABILITY INSURANCE INCLUDING CORPORATE INDEMNITY POLICY APPLICATION PROFIT CORPORATIONS THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY WITH DEFENCE COSTS INCLUDED IN THE LIMIT
More informationNON-PROFIT MANAGEMENT AND CORPORATE LIABILITY INSURANCE POLICY EQUINE D&O PROGRAM NEW BUSINESS APPLICATION
NON-PROFIT MNGEMENT ND CORPORTE LIBILITY INSURNCE POLICY EUINE D&O PROGRM NEW BUSINESS PPLICTION THIS IS N PPLICTION FOR CLIMS MDE POLICY WITH DEFENCE COSTS INCLUDED IN THE LIMIT OF LIBILITY. LL UESTIONS
More information2014 2015 CDECA Program Member Insurance New Business Application
2014 2015 CDECA Program Member Insurance New Business Application SECTION 1: APPLICANT INFORMATION 1. Name of Business: 2. Are you Incorporated? 3. CDECA Membership Number: 4. Name of the Principal / Owner
More informationGENERAL INFORMATION. 12. Has any Insurer declined, cancelled or non-renewed similar insurance for which you are applying? Yes No
NON-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE APPLICATION GENERAL INFORMATION 1. Name of Insured: 2. Mailing Address: 3. Person designated to receive all notices from the Insurer or
More informationDragonshield Proposal Form Broad Form Management Liability Insurance
AIG Insurance Hong Kong Limited Dragonshield Proposal Form Broad Form Management Liability Insurance Notices: In underwriting your application for coverage, the insurer will rely upon the accuracy and
More informationProfessional Risk Facilities,
P R F Professional Risk Facilities, MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY WHICH, SUBJECT TO ITS PROVISIONS,
More informationEMPLOYMENT 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
More informationAIG 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
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION
610-668-7100 MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY
More informationEMPLOYMENT 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
More informationErrors & Omissions Insurance Application
Errors & Omissions Insurance Application THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED CERTIFICATE OF INSURANCE. THE CERTIFICATE APPLIES TO THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND
More informationMISCELLANEOUS E&O LLOYD S OF LONDON
MISCELLANEOUS E&O APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYD S THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY APPLICANT S INSTRUCTIONS 1.
More informationAPPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE PLEASE NOTE:
APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE PLEASE NOTE: Employment Practices Liability Insurance is written on a claims-made basis and covers only Claims first made against the Insured Persons
More information6. 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,
More informationGuide to Professional Liability Insurance HRPA OFFICE OF THE REGISTRAR
2012 Guide to Professional Liability Insurance HRPA OFFICE OF THE REGISTRAR Guide to Professional Liability Insurance TABLE OF CONTENTS Page What is professional liability insurance? 2 What is the professional
More informationMISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY
MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY APPLICATION FOR MISCELLANOUS MEDICAL PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYDS OF LONDON THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE
More informationAPPLICATION 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
More informationBEDFORD UNDERWRITERS, LTD. 315 East Mill St., P. O. Box 278 Plymouth, WI 53073 Ph. (920) 892-8795 (800) 735-1378 FAX (920) 892-8980
BEDFORD UNDERWRITERS, LTD. 315 East Mill St., P. O. Box 278 Plymouth, WI 53073 Ph. (920) 892-8795 (800) 735-1378 FAX (920) 892-8980 APPLICATION FOR PROFESSIONAL LIABILITY ERRORS & OMISSIONS INSURANCE IF
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO
More informationProfessional Liability Errors and Omissions Insurance Application
HCC Specialty 37 Radio Circle Drive Mount Kisco, NY 10549 main (914) 242 7840 facsimile (914) 241 1133 e-mail MPL@hcc.com Professional Liability Errors and Omissions Insurance Application THIS IS AN APPLICATION
More informationLAWYERS 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
More informationFREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS Administration What is the insurance program? Can I apply for non-active status so I don t have to make an insurance payment or take the mandatory continuing education courses?
More informationApplication for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully.
I. Employer Information Agency/Broker: Address: Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully. Name of Employer Office Address Street
More informationTravelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION
Miscellaneous Professional Liability Plus+ SM Travelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION Policy NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT
More informationApplication For Private Company Directors, Officers And Employees Liability Coverage Privately Owned Company
Application For Private Company Directors, Officers And Liability Coverage Privately Owned Company Zurich-American Insurance Group PLEASE NOTE: This Application is for PRIVATELY HELD Companies only. Directors
More informationAPPLICATION 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
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO
More informationProfessional Liability Errors and Omissions Insurance Application
Professional Liability Errors and Omissions Insurance Application PO Box 591 Plainview, NY 11803 T:(516) 396-4600 / F:(516) 396-4610 www.empirebrokerage.com tice: If coverage is issued, It will be based
More informationAPPLICATION 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
More informationHow To Get A Liability Insurance Plan From Scacte
Membership Service Center P.O. Box 45610 Westlake OH 44145 www.scacte.org Finn Laursen Executive Director E-Mail: finn@scacte.org Toll Free (888) 798-1124 Dear SCACTE Member: As an employed professional
More informationAPPLICATION FOR NOT-FOR-PROFIT ENTITY AND DIRECTORS AND OFFICERS LIABILITY INSURANCE INCLUDING EMPLOYMENT PRACTICES CLAIMS COVERAGE
APPLICATION FOR NOT-FOR-PROFIT ENTITY AND DIRECTORS AND OFFICERS LIABILITY INSURANCE INCLUDING EMPLOYMENT PRACTICES CLAIMS COVERAGE NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY.
More informationIRONSHORE INSURANCE COMPANIES One State Street Plaza, 7 th Floor New York, New York 10004 Tel: 646-826-6600 Toll Free: 877-IRON411
IRONSHORE INSURANCE COMPANIES One State Street Plaza, 7 th Floor New York, New York 10004 Tel: 646-826-6600 Toll Free: 877-IRON411 Miscellaneous Professional Liability Insurance Application THE APPLICANT
More information(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:
APPLICATION FOR PARAMEDICS, EMT S, NURSE ANESTHETISTS, NURSE PRACTITIONERS, AMBULANCE SERVICES AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) 1. APPLICANT INFORMATION
More informationEXCLUSIVE ERRORS & OMISSIONS INSURANCE APPLICATION FOR MEMBERS OF THE MORTGAGE BROKERS ASSOCIATION OF BRITISH COLUMBIA
EXCLUSIVE ERRORS & OMISSIONS INSURANCE APPLICATION FOR MEMBERS OF THE MORTGAGE BROKERS ASSOCIATION OF BRITISH COLUMBIA THIS APPLICATION SHALL FORM PART OF ANY ERRORS & OMISSIONS / PROFESSIONAL LIABILITY
More informationKENTUCKY APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
PROFESSIONAL LIABILITY (OTHER THAN MEDICAL) LW AP 04 03 11 KENTUCKY APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. CLAIMS MUST BE FIRST
More informationCANADIAN RED CROSS INSTRUCTORS / TRAINERS (FOR INDIVIDUALS)
CANADIAN RED CROSS INSTRUCTORS / TRAINERS (FOR INDIVIDUALS) NON AQUATICS INSURANCE PROGRAM for ERRORS & OMISSIONS LIABILITY INSURANCE and COMMERCIAL GENERAL LIABILITY INSURANCE We are pleased to enclose
More informationSpecified Professions Professional Liability Product
COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy
More informationSOEP Members Ontario Licensed Optometrists 2016
General Application for Professional Liability Insurance SOEP Members Ontario Licensed Optometrists 2016 Intact Insurance Co. Broker: 3100 Steeles Ave. East, Suite 101, Markham ON L3R 8T3 All questions
More informationSocial Workers' Professional Liability Insurance Endorsement THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CH CG 24 03 02 Social Workers' Professional Liability Insurance Endorsement THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following:
More informationThank you for your interest in the Private Practice Plan
Thank you for your interest in the Private Practice Plan This plan is available to members of the National Association of School Psychologists and the American College Personnel Association. To apply,
More informationTravelers 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
More informationDIRECTORS 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
More informationEidyia 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
More information2. a. Primary Location of the firm: Street Address: City: County: State: Zip: Telephone: Fax:
THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE AND REPORTED POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM BOTH FIRST MADE AGAINST AN INSURED AND REPORTED IN WRITING TO THE COMPANY
More informationMiscellaneous 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
More informationMalpractice 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
More informationTHE HARTFORD DIRECTORS, OFFICERS AND ENTITY LIABILITY INSURANCE APPLICATION (FINANCIAL INSTITUTIONS/FINANCIAL SERVICES) NEW YORK
, a stock insurance company, herein called the Insurer THE HARTFORD DIRECTORS, OFFICERS AND ENTITY LIABILITY INSURANCE APPLICATION (FINANCIAL INSTITUTIONS/FINANCIAL SERVICES) NEW YORK NOTICE: THIS IS A
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION
MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO
More informationNAVIGATORS INSURANCE COMPANY
NAVIGATORS INSURANCE COMPANY APPLICATION FOR LAWYERS' PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED POLICY (must complete in ink) 1. Name of Applicant (type or print)
More informationNEW YORK LAWYERS PROFESSIONAL LIABILITY APPLICATION
UNITED STATES FIRE INSURANCE COMPANY THE NORTH RIVER INSURANCE COMPANY 305 MADISON AVENUE, MORRISTOWN, NJ 07962 NEW YORK LAWYERS PROFESSIONAL LIABILITY APPLICATION NOTICE: COVERAGE FOR WHICH THIS APPLICATION
More informationMPL 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
More informationProperty Managers Professional Package Product
COMMITTED TO A MAKING DIFFERENCE Property Managers Professional Package Product PROPERTY MANAGERS PROFESSIONAL PACKAGE PRODUCT APPLICATION All questions must be answered and application must be signed
More informationNurseInsure Malpratice Errors & Omissions Insurance Program and Business Insurance Program
NurseInsure Malpratice Errors & Omissions Insurance Program and Business Insurance Program Thank you for your interest in the RNAO NurseInsure Program. The following is a summary of the key components
More informationHENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. CANADIAN RED CROSS
HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. CANADIAN RED CROSS INDIVIDUAL INSTRUCTOR / MASTER TRAINER LIABILITY INSURANCE APPLICATION (Non Aquatics) FOR CANADIAN RED CROSS INSTRUCTORS AND MASTER
More informationTHE 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
More informationPROFESSIONAL LIABILITY INSURANCE APPLICATION FOR LAW FIRMS
James River Insurance Company and its Subsidiaries 6641 West Broad Street, Suite 300 Richmond, VA 23230 Application for Law Firms Lawyers Professional Liability PROFESSIONAL LIABILITY Division Email to
More informationGENERAL 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
More informationMISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION COVERAGE PART A PROFESSIONAL LIABILITY INSURANCE COVERAGE THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY Please read your policy
More informationCANADIAN KINESIOLOGY ALLIANCE and ITS PROVINCIAL MEMBER ASSOCIATIONS
CANADIAN KINESIOLOGY ALLIANCE and ITS PROVINCIAL MEMBER ASSOCIATIONS 2013 to 2014 Renewal Proposal Presented by: Joseph V McCabe, FCIP Chief Executive Officer LMS PROLINK Ltd. 480 University Avenue, Suite
More informationNON 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
More informationAmbulance Services, Medical Transport Mainform Application
Applicant Information 1. Applicant name: 2. Principal business address (attach separate sheet if more than one location): 3. Telephone number: 4. Date established: 5. Applicant s practice is a: Solo practitioner
More informationAPPLICATION FOR PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYD S
Program for members of: APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYD S Administered by: This application is for a claims- made insurance policy Applicant Instructions
More informationMPL 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
More informationSample Business Administration Letters of Application
HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR
More informationTORUS 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:
More informationA GUIDE TO PURCHASING LAWYER S PROFESSIONAL LIABILITY INSURANCE IN VIRGINIA
A GUIDE TO PURCHASING LAWYER S PROFESSIONAL LIABILITY INSURANCE IN VIRGINIA Presented By The Virginia State Bar's Special Committee on Lawyer Malpractice Insurance May 2008 The Need For Professional Liability
More informationProfessional Liability Errors and Omissions Insurance Application
If coverage is issued, it will be on a claims-made basis. Notice: this insurance coverage provides that the limit of liability available to pay judgements or settlements shall be reduced by amounts incurred
More informationIndividual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.:
Whenever used in this Application, the term Applicant means the Named Insured and any other entity proposed for coverage. ENDURANCE AGENCY ADVANTAGE APPLICATION THIS IS AN APPLICATION FOR INSURANCE WRITTEN
More informationEZ RENEWAL APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE ABOUT THE FIRM RENEWAL INFORMATION
EZ RENEWAL APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE AND REPORTED POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM BOTH FIRST
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE IMPORTANT NOTICE
IMPORTANT NOTICE THE POLICY FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS-MADE BASIS. IT PROVIDES NO COVERAGE FOR CLAIMS ARISING OUT OF INCIDENTS, SITUATIONS OR ACTS OR OMISSIONS WHICH TOOK PLACE PRIOR
More informationCONTACT INFORMATION FOR RISK MANAGEMENT SERVICES
NEW BUSINESS APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE Farmington Casualty Company Hartford, CT 06183 This application is for a claims-made policy which includes defense expense within the
More informationERRORS & 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
More informationCOURT 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,
More informationNON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY
NON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM (AS DEFINED IN THE POLICY)
More informationDeerfield Insurance Company - A Practical Application
Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED
More informationBusiness Insurance Application For Canadian Counsellors
New Business Insurance Application for Canadian Counsellors Français disponible sur demande. Name: Mailing Address: City: Prov.: Postal Code: Are you the Business Owner? If yes, Name of Business: Number
More informationCONSULTANTS 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,
More informationDIRECTORS, 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
More informationLawyers Professional Liability Insurance Application
Lawyers Professional Liability Insurance Application AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. IF ISSUED, PLEASE READ YOUR POLICY CAREFULLY.
More informationERRORS & 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
More informationTravelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION
Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers Casualty and Surety Company of America Hartford, Connecticut IMPORTANT NOTE: This is an application for
More informationNOT FOR PROFIT APPLICATION DIRECTORS AND OFFICERS, ENTITY AND PERSONAL LIABILITY INSURANCE
NOT FOR PROFIT APPLICATION DIRECTORS AND OFFICERS, ENTITY AND PERSONAL LIABILITY INSURANCE 1. GENERAL INFORMATION This general information must be furnished with respect to each Entity and Plan to be named
More informationAPPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY
Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 rth Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 APPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL
More informationParticipating Agents of American Independent Marketing Group (AIM)
Insurance Brokers of California, Inc Participating Agents of American Independent Marketing Group (AIM) 2008 2009 ERRORS & OMISSIONS INSURANCE PROGRAM ENROLLMENT FORM I elect to participate in the E&O
More informationCanadian Federation of Podiatric Medicine. Endorsed Program
Canadian Federation of Podiatric Medicine Endorsed Program An insurance product specifically designed to meet the needs of CFPM members throughout Canada. $1,000,000 Per claim/$2,000,000 Aggregate COVERAGES
More informationApplication 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
More informationJEWELRY APPRAISERS 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,
More informationProfessional Liability coverage for negligent acts, errors or omissions in the conduct of Arbitration Proceedings and/or Dispute Resolution Services.
Available through The Mediation Association of Colorado exclusively for its Members Professional Liability coverage for negligent acts, errors or omissions in the conduct of Arbitration Proceedings and/or
More informationCalifornia Optometric Association INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR OPTOMETRISTS
California Optometric Association OLP INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR OPTOMETRISTS HOW TO APPLY: 1. You may apply on-line at www.proliability.com, or 2. Complete application
More informationAPPLICATION 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
More informationINSURANCE INDUSTRY PROFESSIONAL LIABILITY COVERAGE UNIT THIS IS A CLAIMS MADE POLICY. PLEASE READ CAREFULLY.
INSURANCE INDUSTRY PROFESSIONAL LIABILITY COVERAGE UNIT THIS IS A CLAIMS MADE POLICY. PLEASE READ CAREFULLY. I. INSURING AGREEMENTS A. INSURANCE OPERATIONS COVERAGE. We will pay on behalf of the insured
More informationApplication 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
More informationPROFESSIONAL LIABILTY APPLICATION
DIRECTIONS: 1. Complete the application (all pages) in full by filling in the blue fields. 2. Please fill in all the fields with the correct information. 3. Email the application to apps@cossioinsurance.com
More informationAllied Health Professional Liability Insurance Application Form
Allied Health Professional Liability Insurance Application Form With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy declarations
More information3. Do you have a full-time Risk Manager? Yes No Risk Manager s name: 4. Website address: Phone number FEIN:
ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Education Legal Liability and Employment Practices
More informationCommercial General Application (Manufacturing/Wholesale/Retail)
Commercial General Application (Manufacturing/Wholesale/Retail) Applicant Information Named Insured: Address of Insured: Desired Effective and Expiration Dates: Broker Information Brokerage Name: Address
More information