APPLICATION FOR SPECIFIED PROFESSIONS

PROFESSIONAL LIABILITY INSURANCE

(Claims Made Basis)

APPLICANT’S INSTRUCTIONS:  
1. Answer all questions.
2. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.

1.   APPLICANT INFORMATION

a.Full name of Applicant:      

b.Principal Office Address:   Address:    City:   State:    Zip:

c.Address of Branch Office: Address:   City:   State:  Zip:

d.Number of Employees:   Full time        Part time     Seasonal            Total  

e.   Corporation        Partnership        Individual            Other       Date established:

Business Phone:

Email Address: 

f. Please list and describe affiliations with other firms:

-

    Yes     No
g.(i) In the past five years has your name changed?    
   (ii) Has any other business been purchased?   
   (iii)  Has any merger taken place?    



If Yes, please attach details - including any changes in operations and key employees.

h.(i) Limits of Liability requested:    $500,000     $1,000,000    Other:     Effective Date:

  (ii) Deductible (per claim) requested:   $2,500   $5,000   $10,000   $25,000   Other:

2. PROFESSIONAL ACTIVITIES AND SPECIALTY

       3. CLAIMS/HISTORY

a. Please describe the professional activities for which coverage is desired and indicate the percentage of gross receipts derived from each activity.

       Please attach details for any “Yes” answers.

a. List any professional liability claims actually made against you in the past five years, including status of claim, amounts demanded or paid, date of claim, and action taken to prevent the same type of claim in the future.

 

b.Fees and Receipts:   

Estimate for:   
Coming Year:  
Past 3 Years:

20 est.

20 est.

20 est.

c. Are you engaged in any business or profession other than as described in Item 2(a)? 
Yes  No

If Yes, please explain.

b.Please list any known incidents which might give rise to a professional liability claim.
c.Has any insurer canceled or refused to renew any similar
insurance during the past five years?     Yes  No

d.Have you established a quality control and/or continuing education program to limit professional liability exposure? Yes  No

Please explain:


3.   CLAIMS/HISTORY (CONTD.)

d.   Previous coverage:

Policy
Period

Insurer 

Indicate whether
claims made or
occurrence policy

Limits of Liability

Deductible

Retro
Date

e.   Computer Systems:

(i)    Do your computer systems store a four-digit year?  Yes  No

(ii)   If NO, please attach a description of corrective measures taken and the date upon which you
      anticipate the problem will be solved.

4.   ADDITIONAL INFORMATION

a.   Please attach a list of:

(i)    Partners, key employees, etch, and their professional qualifications;

(ii)   Professional societies and organizations to which they or you belong(s); and

(iii)  Your five largest jobs in the past three years.

b.   Please attach copies of:

(i)    Advertisements, brochures, descriptive literature;

(ii)   Sample contract for services between you and your clients; and

(iii)  Latest financial data (annual report or balance sheet and income statement).


* NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.

WARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy.  I/We authorize the release of claim information from any prior insurer to Business Insurance Distributers, Inc.

Name of Applicant:     Title (Officer, partner, etc.):

Signature of Applicant : ___________________________   Date:  _____________________

SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.

Please press the Submit Button ONCE.
Then wait for online confirmation of your request.
Thank you for your interest.