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Commercial – Professional Liability

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Commercial - Professional Liability

Name of applicant*
First Last
Address of applicant*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website
Additional Information
Status*
Date firm was established*
MM slash DD slash YYYY
Please describe in detail the services provided for which coverage is desired (include percent of total receipts):*
Are there other services provided by the applicant?*
- Yes
- No
If yes, please provide list of services
Please list the projected gross for the next 12 months for the services provided*
Please provide the gross receipts for the past 12 months for the services provided*
Please provide the gross receipts for one year prior to the services provided*

List the applicants last 5 largest jobs over the past 3 years*

Client name	Services provided	Revenue/One year

Does the Applicant firm have any subsidiaries or affiliates for which coverage is desired?*
- Yes
- No
If yes, provide applicant name
First Last
Description of operations
Percentage of ownership by the Applicant or, if not applicable, description of affiliation with the Applicant.
Is the Applicant firm controlled, owned or associated with any other firm, corporation or company?*
- Yes
- No
Are any activities listed in this application provided to such an affiliated enterprise?*
- Yes
- No
If yes plese explain
Number of principals, officers and partners of the firm*
Number of other professional employees*
Number of non-professional employees (clerks, secretaries, etc.)*

Please list any professional associations to which the Applicant belongs:*

Please list any professional designations held by any principals, owners or staff:*

Please list any professional licenses held by any principals, owners or staff:*

Does the Applicant use a written contract with all clients?*
- Yes
- No
If not, approximately what percent of time are contracts not used?
Please explain why contracts are not used:
Are contracts reviewed by legal counsel?*
- Yes
- No
Does the Applicant have procedures to ensure compliance with Federal, State and Local Statutes?*
- Yes
- No
If yes, please attach a copy of the procedure or provide a detailed description on a separate sheet.
Max. file size: 50 MB.
Does the applicants contrct conatain harmless or indemnity agreements?*
- Yes
- No
Is the applicants contract in favor of the applicant?*
- Yes
- No
Does the applicants contract contain acceptance of consequential damages*
- Yes
- No
Has a client ever refused to pay for services rendered by applicant?*
- Yes
- No
If yes, describe
What is the customer’s potential for consequential damages and resulting monetary loss due to product or service failure by your company? *
What percentage of the Applicant’s business involves subcontracting of work to others?*
If so, does the Applicant require evidence of professional liability insurance from subcontractors?*
- Yes
- No
Does the Applicant have a procedure for following up on complaints?*
- Yes
- No
If yes, please upload a copy
Max. file size: 50 MB.

Please list all prior professional liability insurance coverage:*

Insurer	Limit Carried	Deductible	Premium	Expiration date

If coverage is currently in force, what is the retroactive date?*
MM slash DD slash YYYY
Has any application for any other insurance on behalf of the Applicant or any of its predecessors in business been declined or cancelled, or renewal of such insurance been refused?*
- Yes
- No
If yes, please explain
Does the Applicant currently maintain General Liability coverage?*
- Yes
- No
If so, who is your carrier?
Limit of liability
Effective dates
Limit of Liability desired:*
Deductible desired*
Has the Applicant or any of its principals, partners, officers or directors been the subject of any disciplinary action by the authorities or any professional association?*
- Yes
- No
If yes, please explain
Does any person to be insured have knowledge of any fact, circumstance or situation or act, error or omission which may result in a Claim against him or the Applicant under the proposed policy?*
- Yes
- No
Has any claim or claims been made against the applicant or any of its predecessors in business, or any of the past or present partners, owners, officers or employees during the last five years?*
- Yes
- No
If yes, please attach an explanation of each such claim
Max. file size: 50 MB.
Please attatch a current annual report*
Max. file size: 50 MB.
Please attatch promortion materials or brochures*
Max. file size: 50 MB.
Resumes of the principals if less than five years of operation*
Max. file size: 50 MB.
A copy of a sample contract and/or engagement/proposal letter*
Max. file size: 50 MB.
Phone
This field is for validation purposes and should be left unchanged.

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