PLAZA. Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "PLAZA. Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage"

Transcription

1 PLAZA INSURANCE COMPANY a member of the State Auto Group Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage GENERAL INFORMATION Parent Organization: Address: Website: State of Incorporation: Date Established: Nature of Operations: Limits Requested: Retention Requested: Policy Period requested: From: To: Provide the following information for the current fiscal year: Total Assets: Revenue: Fund Balance: Net Income: SUBSIDIAIRES YES NO Do you want to include all Subsidiaries?... Does the Organization, any Subsidiary, or any proposed Insured presently act in the capacity of general partner in any limited or general partnership?... If Yes, please attach list of partnerships and their service or business function. Does the Organization have any for-profit Subsidiaries?... OPERATIONS Is the Organization and its Subsidiaries exempt from Federal and State income taxes?... If yes, under what provision (i.e. 501(c)3, 501(c)4, etc.)? Has the status of the Organization s tax exemption ever been challenged?... Is the Organization a cooperative of any type?... Does the Organization or any Subsidiary publish any magazines, periodicals, or newsletters?... Does the Organization or any subsidiary offer or perform any professional review, certification, or accreditation services?... MK-939 MK-922 Plaza (07/11) Insurance (10/11)

2 YES Does the Organization or any subsidiary take any disciplinary action or recommend disciplinary action as a result of peer review group activities?... NO Has the Organization or any subsidiary had any acquisitions or divestitures in the past three (3) years?... Does the Organization or any subsidiary provide a referral service, legal aid service, or computer service to its members or the public?... Does the Organization or any subsidiary engage in any form of research, development, experimentation or testing?... PAST ACTIVITIES Has the Organization, any Subsidiary, or proposed Insured been involved in any of the following: Anti-Trust, copyright or patent litigation?... Civil or criminal actions or administrative proceedings charging violation of any federal or state law or regulation or any other criminal action?... Representative actions, class actions or derivative suits?... Investigations or inquiries by any Federal, State or local authorities?... Has the Organization or any Subsidiary changed auditors in the past three (3) years?... Have any Loss payments been made on behalf of any proposed Insured under any directors and officers or employment practices liability coverage or similar insurance or endorsement?... If Yes, to any preceding questions attach details. EMPLOYMENT PRACTICES INFORMATION Enter the number of employees in the appropriate boxes below. Domestic Non Union Union Full Time based in California Part Time based in California Full Time based in FL, MI, TX & Washington DC Part Time based in FL, MI, TX & Washington DC Full Time all other states Part Time all other states TOTAL ALL STATES Full Time Foreign Employees Part Time Foreign Employees Leased Employees Volunteers Independent Contractors Seasonal Employees Temporary Employees TOTAL - OTHER OTHER

3 Number of employees with total annual compensation greater than $100,000 YES NO Number of employees terminated or laid off in past 12 months What was the annual employee turnover rate for the last (3) three years? Past Year: % 1 Year Prior: % 2 Years Prior: % Does the Applicant have a Human Resources or Personnel Department?... Does the Applicant have an Employee Handbook?... Is the Employment Handbook distributed to all employees or maintained on an Internet location informing employees of their employment rights?... Are employees required to certify that they have reviewed the employee handbook and will comply with the terms and conditions?... Does the Employee Handbook address the following issues: Prohibiting Discrimination... Prohibiting Sexual Harassment... Compliance with the Americans with Disabilities Act... Compliance with the 1991 Civil Rights Act... Compliance with the Family Medical Leave Act... Employee disciplinary actions... Terminations and layoffs... Employee appraisals / reviews... Formal at will statement... Written grievance procedure... Open Door Policy... Guidelines regarding Office Romances / Disclosures... Definitions for exempt and non exempt employees... Computer and Internet use policy... Social Media Policy... Drug and Alcohol use... Does the Applicant and any of its Subsidiaries conduct employee training with regards to discrimination and harassment?... Is there a formal process for employees to report complaints, which states that the reporting of these matters will not result in disciplinary or retaliatory action?... Has Legal Counsel reviewed the Employee Handbook?... Does the Applicant post its policies and procedures?...

4 YES Has the Applicant or any Subsidiary undergone or will it be undergoing any of the following employment activities? Layoffs over the last three (3) years?... NO Currently ongoing layoffs?... Layoffs expected in the next twelve (12) months?... If yes to any of the above, provide additional details, including the percentage of employees, on a separate attachment. Does the Applicant or any Subsidiary use outside counsel to handle the layoff process (including any reduction in force )?... Is it the policy of the Applicant or any Subsidiary to offer severance packages in exchange for releases not to sue?... Has the Applicant or any Subsidiary ever had a claim brought against it by a nonemployee third party alleging harassment, discrimination or any violation of civil rights?... If Yes, attach details. Does the Applicant or any Subsidiary have established policies or procedures detailing employee conduct when dealing with third parties, including nondiscrimination statements?... PAST ACTIVITIES AND CURRENT COVERAGE Has the Parent Company, or any Subsidiary or any proposed Insured Person given written notice under the provisions of any prior or current Directors & Officers Liability policy, Employment Practice Liability policy or any similar insurance or endorsement of specific facts or circumstances which might give rise to a Claim being made against any Insured?... If Yes, provide details. Have any Loss payments been made on behalf of any Insured under any Directors & Officers Liability policy, Employment Practice Liability Policy or similar insurance or endorsement?... If Yes, provide details. It is agreed and understood that any Claim(s) arising from any facts, circumstances, or situations mentioned in this Section are excluded from coverage. CURRENT COVERAGE Name of Insurance Company Limit of Liability Self Insured Retention Policy Effective Date Premium Pending and Prior Litigation Date Directors and Officers Employment Practices Liability Has any insurance carrier refused, canceled or non-renewed any Directors, Officer or Employment Practices insurance coverage*?... If Yes, attach complete details including when and reason(s).

5 PRIOR KNOWLEDGE IT IS IMPORTANT THAT YOU COMPLETE ONE OF THE BLANKS IN THIS PARAGRAPH. No person proposed for coverage is aware of any facts, circumstances, investigations or actions which he or she has reason to suppose might give rise to a future Claim that would fall within the scope of proposed coverage, except None; Or It is agreed that if such facts, circumstances, investigations or actions exist, whether or not disclosed, any Claim arising from them is excluded from this proposed coverage. Attach copies of the following for the Applicant and, to the extent available, each of its Subsidiaries: Most recent annual audited and interim financial statements Organizational chart of applicant including all subsidiaries to be insured under this policy including each Subsidiary s tax status, affiliation and the percentage of ownership by the Applicant Employee Handbook EEO-1 Report if applicable A copy of the by-laws, charter, or articles of incorporation to include indemnification provisions IMPORTANT INFORMATION The submitting of this Application does not obligate the Insurer to issue a coverage section. You will be advised if your Application for insurance is accepted. FALSE INFORMATION Any person who, knowingly and with the 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. MATERIAL CHANGE Signing of this Application does not bind the Parent Organization or the Insurer. If there is any material change in the answers to the questions prior to the Policy inception date the Parent Organization will notify the Insurer in writing and any outstanding quotation or indication may be modified or withdrawn. DECLARATION AND SIGTURE The undersigned declares that to the best of his or her knowledge and belief that the statements set forth herein are true. Although the signing of this Application does not bind the undersigned on behalf of the Parent Organization or any other proposed Insured to effect insurance, the undersigned agrees that this Application and its attachments shall be the basis of the contract should a Policy be issued and shall be deemed attached to and shall form part of the Policy. The Insurer is hereby authorized to make any investigation and inquiry in connection with this Application that it deems necessary. Application must be signed by the Chairman of the Board, President or Chief Executive Officer. Date Signature Title

6 NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM- PANY 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 CONCERN- ING ANY FACT MATERIAL THERETO, COMMITS A FRAUDU- LENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMIL AND CIVIL PELTIES. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMA- TION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINE- MENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEAD- ING FACTS OR INFORMATION TO AN INSURANCE COMPA- NY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE INSURANCE COMPANY. PELTIES 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DE- PARTMENT OF REGULATORY AUTHORITIES NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARN- ING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PEN- ALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN AD- DITION, 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 IN THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSUR- ANCE COMPANY OR OTHER PERSON FILES AN APPLICA- TION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSUR- ANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIA 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 FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOW- INGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PELTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BEN- EFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSUR- ANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMIL AND CIVIL PELTIES. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILI- TATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PER- SON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAIN- ING ANY FALSE, INCOMPLETE OR MISLEADING INFORMA- TION IS GUILTY OF A FELONY (365: , ). NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN AP- PLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFOR- MATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMIL AND CIVIL PELTIES. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON AP- PLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN IN- SURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PELTIES INCLUDE IMPRIS- ONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN AP- PLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFOR- MATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMIL AND CIVIL PELTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN AP- PLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMA- TION CONCERNING ANY FACT MATERIAL THERETO, COM- MITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PELTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

Total Number Active Number Total Type Full Name of Plan of Plan of Plan Plan of Participants Participants Assets Plan*

Total Number Active Number Total Type Full Name of Plan of Plan of Plan Plan of Participants Participants Assets Plan* PLAZA INSURANCE COMPANY a member of the State Auto Group Application for Fiduciary Liability Coverage GENERAL INFORMATION Parent Company: Address: Website: State of Incorporation: Years of Operation: Type

More information

APPLICATION 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 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 information

EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION

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

More information

DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION

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

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION

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

More information

DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION

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

More information

Application For ACE EXPRESS Non Profit Organization Management Indemnity Package

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

More information

NON PROFIT MANAGEMENT LIABILITY 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

More information

Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations

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

More information

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 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 information

Nonprofit Directors & Officers Liability Insurance

Nonprofit Directors & Officers Liability Insurance Nonprofit Directors & Officers Liability Insurance CLAIMS MADE WARNING FOR APPLICATION THIS PROPOSAL FORM IS FOR A CLAIMS MADE AND REPORTED POLICY, RELATING TO CLAIMS MADE AGAINST THE INSUREDS DURING THE

More information

ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION

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

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION

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

More information

INSTRUCTIONS FOR COMPLETING THIS APPLICATION

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

More information

Admiral Insurance Company

Admiral Insurance Company Executive Liability Insurance Proposal Form for Employment Practices Liability CLAIMS MADE WARNING FOR APPLICATION: This Proposal Form is for a Claims Made and Reported Policy, relating to claims made

More information

APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE

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

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

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

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION

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

More information

THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY

THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY FLEXI PLUS FIVE APPLICATION NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE EMPLOYMENT PRACTICES LIABILITY INSURANCE FIDUCIARY LIABILITY INSURANCE WORKPLACE VIOLENCE COVERAGE INTERNET

More information

DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION

DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION 111 Warren Road - Suite 1B Cockeysville, MD 21030 CALL: 1-800-759-7779 FAX: 410-628-6914 http://www.interstate-insurance.com BEAZLEY DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION

More information

APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE

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

More information

Miscellaneous Professional Liability Application

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

More information

RENEWAL Application for Business and Management (BAM) Indemnity 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

More information

6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:

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,

More information

Hudson Insurance Company 100 William Street, New York, NY 10038

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

More information

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) 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

More information

Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE

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

More information

NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY INSURANCE POLICY APPLICATION

NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY INSURANCE POLICY APPLICATION NON-PROFIT ORGANIZATION MANAGEMENT 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 information

Coverage Section(s) Requested

Coverage Section(s) Requested i ll Proposal Form Management Liability Insurance CLAIMS MADE WARNING FOR APPLICATION: This Proposal Form is for a Claims Made and Reported Policy, relating to claims made against the Insureds during the

More information

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 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

More information

PROPOSAL FOR DIVERSIFIED BUSINESS ORGANIZATION AND MANAGEMENT LIABILITY INSURANCE

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

More information

NON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY

NON-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 information

APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS

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

More information

IRONSHORE 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 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

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

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

More information

Application For Business and Management (BAM) Indemnity Insurance

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

More information

Most Recent FYE (Month/Year) ( / ) Current Assets $ $ Total Assets $ $

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,

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

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

More information

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 ) 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.

More information

APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION

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

More information

Property Managers Professional Package Product

Property 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 information

Financial Institutions Bond Application Form 25 for Insurance Companies New Business Application

Financial Institutions Bond Application Form 25 for Insurance Companies New Business Application General Information 1. Name of Applicant: Address of Applicant: Please attach a list of all subsidiaries including operations, percent of ownership and the date acquired or created. (te: The application

More information

RENEWAL Application for Business and Management (BAM) Indemnity 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

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

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

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

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

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY

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

More information

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ).

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ). Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Markel Insurance Company Associated International Insurance Company

More information

Executive Protection Portfolio SM Fiduciary Liability Coverage Application

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,

More information

Executive Risk Indemnity Inc.

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

More information

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION

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

More information

Malpractice Insurance For International Board Certified Lactation Consultants

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

More information

New Business Application. Real Estate Professional Liability (E&O) Insurance

New Business Application. Real Estate Professional Liability (E&O) Insurance New Business Application The Hanover Insurance Company 440 Lincoln Street, Worcester, MA 01653 Citizens Insurance Company of America 645 West Grand River Avenue, Howell, MI 48843 Please submit application

More information

LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION

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

More information

APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 25 FOR INSURANCE COMPANIES

APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 25 FOR INSURANCE COMPANIES This form must be completed for each new bond and at each premium anniversary. If more space is needed to answer any of the questions contained herein, attach additional sheets. Application is hereby made

More information

Eidyia Insurance Services

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

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

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

More information

AIG CORPORATE IDENTITY PROTECTION

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

More information

UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY A. GENERAL INFORMATION

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

More information

ERRORS & OMISSIONS RENEWAL APPLICATION

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

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY

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

More information

NON OWNED & HIRED AUTO

NON OWNED & HIRED AUTO 1. Applicant Information A) Name (First named insured and other named insureds) OWNED AUTO LIABILITY B) Do you own any vehicle (in your company s name)? If yes, who is the insurer of these vehicles? C)

More information

6. Number of employees including principals: Full-time Part-time Seasonal Total

6. Number of employees including principals: Full-time Part-time Seasonal Total Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY )

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"

More information

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 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

More information

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION

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

More information

GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application

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

More information

NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY

NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY BOLLINGER INC. 101 JFK PARKWAY SHORT HILLS, NJ 07078 NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY PART I GENERAL

More information

GENERAL INFORMATION. Telephone Number: Fax Number: Email Address: Web Address:

GENERAL INFORMATION. Telephone Number: Fax Number: Email Address: Web Address: 1 st Choice Real Estate Services Professional Liability Coverage Application SM Travelers Casualty and Surety Company of America THE INFORMATION BEING REQUESTED IS FOR A CLAIMS MADE POLICY. IT IS IMPORTANT

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) 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

More information

Title Agents Professional Liability Application

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

More information

APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS

APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS SPONSORED BY: AMERICAN SOCIETY OF ASSOCIATION EXECUTIVES MEDIA/PROFESSIONAL INSURANCE a business unit of

More information

ESTATE LAWYERS PRIOR ACTS COVERAGE APPLICATION

ESTATE LAWYERS PRIOR ACTS COVERAGE APPLICATION ESTATE LAWYERS PRIOR ACTS COVERAGE APPLICATION This is an Application for a Claims Made and Reported in Writing Prior Acts Reporting Period If the space given is insufficient, please attach a separate

More information

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110

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

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS

More information

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application

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

More information

INSURANCE COMPANY PROFESSIONAL LIABILITY INSURANCE APPLICATION

INSURANCE COMPANY PROFESSIONAL LIABILITY INSURANCE APPLICATION i NAME OF INSURANCE COMPANY TO WHICH APPLICATION IS MADE: (herein called the Company) INSURANCE COMPANY PROFESSIONAL LIABILITY INSURANCE APPLICATION IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS

More information

Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION

Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION Name of Insurance Company To Which Application is Made Name of Insurance Company

More information

BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER )

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

More information

National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL 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

More information

Lexington Insurance Company

Lexington Insurance Company BURGLAR & FIRE ALARM, AND TELECOMMUNICATIONS PROPERTY Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant

More information

PROPERTY MANAGER SUPPLEMENTAL APPLICATION

PROPERTY MANAGER SUPPLEMENTAL APPLICATION Name of Insurance Company to which Application is made PROPERTY MANAGER SUPPLEMENTAL APPLICATION This is a supplement to an application for a CLAIMS-MADE and Reported Policy. It is to be used solely in

More information

ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL INSURANCE APPLICATION

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

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must

More information

What would you do if your agency had a data breach?

What would you do if your agency had a data breach? What would you do if your agency had a data breach? 80% of businesses fail to recover from a breach because they do not know this answer. Responding to a breach is a complicated process that requires the

More information

LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION

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

More information

PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION

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

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE PLEASE NOTE:

APPLICATION 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 information

Travelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION

Travelers 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 information

Individual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.:

Individual 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 information

CONTACT INFORMATION FOR RISK MANAGEMENT SERVICES

CONTACT 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 information

Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION

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

More information

GENERAL LIABILITY SUPPLEMENTAL APPLICATION

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

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL 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 information

APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE

APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO CLAIMS FIRST MADE DURING

More information

Primary Commercial Liability Insurance Application

Primary Commercial Liability Insurance Application Name of Insured:(Attach separate sheet if necessary) Address of Insured: Provide names of any subsidiaries or affiliated company(s) to be covered: 1. 2. 3. List all additional insureds to be named with

More information

ACE Advantage. Employed Lawyers Professional Liability Application

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

More information

Part 1: APPLICANT INFORMATION

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

More information

SmartPro Property Managers E&O Application

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

More information

ACE DigiTech SM Digital Technology & Professional Liability Small Business Application

ACE DigiTech SM Digital Technology & Professional Liability Small Business Application Westchester Fire Insurance Company ACE DigiTech SM Digital Technology & Professional Liability Small Business Application NOTICE The Policy for which you are applying is written on a claims-made and reported

More information

THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION

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

More information