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 carefully Name of Applicant (Entity referred to as applicant throughout this application form) Address City State Zip Code Phone E-Mail Date established Please describe in detail the professional services for which coverage is desired: Have there been any changes in the nature of the Applicant s business in the last 12 months? If yes, please attach details. What does the applicant see as the potential exposure to a professional liability claim? List total Gross Receipts derived from the professional services rendered: Last year Current year (based on 12 months) Forecast for next year Has or will the applicant undertake any work outside of the United States of America? 1/5
Please provide the following: Name of Partners, Principals, and Key Employees: Number of Years in Practice (of those specified above) Is the Applicant a licensed Professional? If yes, please advise type of licensed Professional: Is the Applicant qualified, as required by Law or Regulation? Has the Applicant ever had their licence revoked or suspended or been fined or disciplined in any way or been the subject of any investigation by any form of regulator? Does the Applicant use a written contract or letter of engagement with clients? In all cases Sometimes Never Does any director, officer, employee, partner or independent/ subcontractor of the Applicant serve as an officer or on the Board of Directors of any client or own any financial or equity interest in any client of the Applicant? If yes, attach an explanation Does the Applicant anticipate deriving more than 75% of total gross billings for the coming year from a single client? If Yes, advise details on a separate sheet. Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company? If Yes, please provide name(s) and relationship(s): During the past 12 months has the name of the firm been changed or has any other business been acquired, merged into, or consolidated with the proposed Applicant? 2/5
Does the Applicant have any Subsidiaries? If Yes, Please list on a separate sheet and advise if coverage is to apply to them. Describe the Applicant s 3 largest jobs or projects during the past 3 years. Name of Client Services Provided Gross Billings Provide the number of principles, partners, officers and professional employees directly engaged in providing services to clients: Sub Contractors / Additional Insured(s) information Provide the number of independent/sub contractors What is the total percent of Applicant s work done by independent contractors and subcontractors. Does the Applicant desire to provide coverage for independent contractors, while working on your behalf? If Yes to the above, please answer the following questions: How will the Applicant utilize each independent/subcontractor? Does the Applicant require Certificates of Professional Liability Insurance from all independent contractors? Additional Insured(s) to be included for Errors and Omissions: Name Address Relationship to Applicant Claims Information Has the Applicant initiated litigation against any of their clients in the past 5 years? If Yes, advise how many times you have initiated litigation in the past 5 years along with details for each: 3/5
During the past 5 years, has any claim been made or suit brought against the Applicant, its predecessor(s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? If Yes, please provide details on a separate supplemental claim application. After enquiry is the applicant aware of any circumstances or allegations that may lead to a claim, being made against the applicant, its predecessor(s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? If Yes, please provide details on a separate claim supplement. Have all claims and circumstances identified in the above questions already been reported and accepted by a current or past Insurer? If No, please attach details. Professional Liability Insurance Coverage Has any policy, or Application for professional liability insurance, on the Applicant s behalf or on the behalf of any of the Applicant s principles, officers, employees, independent contractors, or on behalf of any predecessor(s) in the Applicant s business ever been declined, cancelled or renewal refused? If Yes, advise details: Is similar professional liability insurance currently in force? If Yes, please advise: Name of Carrier Limit Retroactive Date Deductible Premium Policy Period Length of time coverage has continuously been in force: 4/5
COVERAGE PART B - GENERAL LIABILITY INSURANCE COVERAGE THIS APPLICATION IS FOR A LOSSES OCCURRING INSURANCE POLICY Please read your policy carefully Does the Applicant currently have General Liability Insurance? If Yes, please advise the following: Name of Carrier Limit Premium Expiration Date Additional Insured(s) to be included for General Liability: Name Address Relationship to Applicant Has any policy, or Application for General Liability insurance, on the Applicant s behalf or on the behalf of any of the Applicant s principles, officers, employees, independent contractors, or on behalf of any predecessor(s) in the Applicant s business ever been declined, cancelled or renewal refused? If Yes, advise details: Has the Applicant had any General Liability claims paid, reserved or pending during the last 5 years? If Yes, please provide details on a separate claim supplement. NOTICE TO THE APPLICANT The undersigned declares that to the best of his/her knowledge and belief that statements set forth herein are true. The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriters and the Underwriters may withdraw or modify any outstanding quotations. The Underwriter is hereby authorized, but not required to make an investigation and inquiry in connection with the information, statements and disclosures provided in this application. The decision of the Underwriter not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Underwriter and shall not stop the Underwriter from relying on any statement in this application. The signing of this application does not bind the undersigned to purchase the Insurance, nor does the review of this application bind the Underwriter to issue a policy. It is understood the Underwriter is relying on this application in the event the policy is issued. It is agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become a part of this Policy. Signature (Must be an officer of the Applicant) Date Name Title 5/5