Commercial Lines – Professional LiabilityEmet Digital2019-01-02T11:58:35-08:00 Get started by filling out this form and someone from our team will contact you shortly! Commercial - Professional Liability Name of applicant* First Last Address of applicant* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Additional InformationStatus*CorporationPartnershipIndividualOtherDate 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 servicesPlease 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 nameServices providedRevenue/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 operationsPercentage 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 explainNumber 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, describeWhat 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 copyMax. file size: 50 MB.Please list all prior professional liability insurance coverage:*InsurerLimit CarriedDeductiblePremiumExpiration 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 explainDoes the Applicant currently maintain General Liability coverage?* Yes No If so, who is your carrier? Limit of liabilityEffective dates Limit of Liability desired:*$250,000$500,000$1,000,000$2,000,000$5,000,000Deductible desired*$2,500$5,000$10,000$25,000Has 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 explainDoes 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 claimMax. 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.NameThis field is for validation purposes and should be left unchanged.
