Specified Professions Professional Liability Application - All States

This application is for a Claims Made policy. Please read your policy carefully. Defense costs shall be applied against the deductible (except in New York). Applicant may qualify for an INSTANT QUOTE by completing Section I below. Section II answers will be required prior to binding and are subject to underwriting.

I. INSTANT QUOTE INFORMATION

Instant quote is not available for accounts with losses in the past five years. If there is loss history, please complete Section I and submit details in a claim supplement.

Applicant's Name:*

Prefix First Last Suffix

Location Address:*

Street Address Address Line 2 City State ZIP Code

Same as Mailing Address:*

Yes
No

Mailing Address:

Street Address Address Line 2 City State ZIP Code

Website Address:*

Email Address of Primary Contact:*

Description of Operations:*

List 12 month gross receipts below:

Last Year:*

$

Current Year:*

$ (based on 12 months)

Forecast for Next Year:*

$

(a) Number of principals, partners, officers and professional employees directly engaged in providing services to clients:*

(b) Number of Independent/subcontractors:*

Does the Applicant provide services not disclosed above?*

Yes
No

If Yes, Please detail additional services:

II. UNDERWRITING INFORMATION

1. a) Date established:*

b) If business has been in operation less than one year, please provide principal, partner or key employee’s resume.*

Max. file size: 300 MB.

2. a) Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company?*

Yes
No

b) Is any director, officer or partner either affiliated, employed by or associated with any other firm, corporation or company?*

Yes
No

If Yes to either 2a or 2b, please provide names(s) and relationship(s):

Name	Relationship

Please use the + button to the right to add additional names & relationships

3. a) Does the applicant have any subsidiaries?*

Yes
No

b) Name(s) of any subsidiaries:

Please use the + button to the right to add additional Names of Subsidiaries.

c) Are all subsidiaries’ receipts and services disclosed on this application?*

Yes
No

4. Applicant is:*

Corporation
Partnership
Individual
LLC.
Non-Profit

5. Please answer the following questions regarding the use of independent contractors:

a) Do the independent contractors provide the same services as the applicant?*

Yes
No

If No, please describe services:

b) Do the independent/subcontractors work exclusively for the Applicant?*

Yes
No

c) Are all independent contractors required to carry errors and omissions insurance?*

Yes
No

d) Does the Applicant desire to provide coverage for independent contractors as insureds under the policy?*

Yes
No

6. What percentage of current 12-month Gross Receipts are derived from the following:

a) Services performed outside the U.S. or its territories:*

%

b) Clients for which the Applicant is more than a three percent (3%) shareholder:*

%

c) Clients for which any director, officer, employee, partner or independent contractor of the applicant serves as an officer or on the board of directors:*

%

7. Describe the 3 largest jobs or projects during the past 3 years*

Name of Client	Services Provided	Gross Bills

Please use the + button to the right to add additional jobs.

8. Is similar professional liability insurance currently in force?*

Yes
No

8. Is similar professional liability insurance currently in force?*

Carrier	Limit	Deductible	Premium	Retroactive Date:

9 a. Describe your contract usage / engagement letter usage:*

Always Used
Sometimes Used
Never Used

b. Does the Applicant’s contract contain both a hold harmless and indemnification clause?*

Yes
No

b. Does the Applicant’s contract contain both a hold harmless and indemnification clause?*

Yes
No

c. Does the Applicant’s contract clearly define the scope of services that are being performed?*

Yes
No

(Attach a statement of details for all “yes” answers to the following questions)

10. Has any prospective insured ever had their license revoked or suspended or been fined or disciplined in any way or been the subject of any investigation by any regulating body related to their profession?*

Yes
No

Statement of Details:

11. Have you initiated litigation against any of your clients in the past five years?*

Yes
No

Statement of Details:

12. During the past five 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?*

Yes
No

Statement of Details:

13. Is any owner, partner, officer, director, employee or independent contractor aware of any circumstance, allegation, contention, or incident which may result in a claim being made against the Applicant, its predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees or independent contractors?*

Yes
No

Statement of Details:

14. Has any Policy or Application for professional liability insurance on your behalf or on the behalf of any of your principals, officers, employees, independent contractors or on behalf of any predecessor(s) in business ever been declined, cancelled or renewal refused? (Not applicable in Missouri)*

Yes
No

Statement of Details:

III: GENERAL LIABILITY AND PROPERTY INFORMATION

15. Do you currently maintain an active general liability policy?*

Yes
No

16. Has the Applicant had any General Liability or Property claims paid, reserved or pending in the last five years?*

Yes
No

If “Yes,” please provide details:

17. Business Personal Property Limit $*

18. Construction:*

Frame
Joisted Masonry
Masonry non-combustible
Mod. fire-resistive
Fire-resistive

19. Protection class:*

(1-9)

20. What type of burglar alarm is on the premises ?*

Central Station
Local
None

21. Is the premises residential or commercial?*

Residential
Commercial

22. Is 100% of the electric wiring on functioning and operating circuit breakers?*

Yes
No
Not applicable - building built after 1978

23. Is there any aluminum wiring or knob and tube wiring?*

Yes
No
Not applicable - building built after 1978

24. Are there functioning and operational smoke and/or heat detectors?*

Yes
No

IV. ADDITIONAL INSURED INFORMATION

Name:	Interest:	Address:

Coverages Needed:*

Additional Insured Status:
Waiver of Transfer of Rights of Recovery (GL Only)
Primary & Non-Contributory wording (GL Only)

GL
E&O

V. SUPPLEMENTAL APPLICATIONS

Please provide corresponding supplemental applications if applicant’s description of services include any of the following:*

Collection Agency
Financial Planning
Mortgage Field Inspector/ Property Preservation Services

FRAUD STATEMENTS

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.

Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties 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 department of regulatory agencies.

District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Fraud Statement: 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 of the third degree.

Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and confinement in prison.

Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. A binder may not be withdrawn but a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and insurance company 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 concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty.

Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form part of, this policy. I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the company the right to rescind it.

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company 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 concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.

Vermont Fraud Statement: 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 may be subject to fines and confinement in prison.

Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Utah Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Fraud Statement (All Other States): 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.

Producer Name:*

Retail Agency Name:*

License #:*

Main Agency Phone Number:*

Agency Mailing Address:*

Street Address Address Line 2 City State ZIP Code

New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company 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 concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicant's Signature:*

Title:*

Date:*

I acknowledge that the information provided in this application is material to acceptance of the risk and the issuance of the requested policy by Company. I represent that the information provided in this application is true and correct in all matters. I agree that any claim, incident, occurrence, event or material change in the Applicant’s operation taking place between the date of this Application was signed and the effective date of the insurance policy applied for which would render inaccurate, untrue or incomplete, any information provided in this Application, will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations and/or void any authorization or agreement to bind the insurance. Company may, but is not required, to make investigation of the information provided in the Application. A decision by the Company not to make or to limit such investigation does not constitute a waiver or estoppel of Company’s rights.

Specified Professions Application

Specified Professions Application

Specified Professions Professional Liability Application - All States

I. INSTANT QUOTE INFORMATION

II. UNDERWRITING INFORMATION

III: GENERAL LIABILITY AND PROPERTY INFORMATION

IV. ADDITIONAL INSURED INFORMATION

V. SUPPLEMENTAL APPLICATIONS

FRAUD STATEMENTS