1.
Name of Applicant:
Address:
Contact Name:
Phone:
Email:
2.
Limit of Liability Desired:
$500,000
$1,000,000
$2,000,000
Other
If other, please specify:
3.
Deductible:
$5,000
$10,000
$25,000
Other
If other, please specify:
4.
Please describe in detail the professional
activities for which coverage is desired:
5.
Is the applicant engaged in any business
or profession other than as described in item 4?
Yes
No
If YES, please attach an explanation
and estimated revenues.
6.
List the total gross revenues for the
past two years derived from those activities in Question
4. In addition, please list projected revenues for the
current year.
7.
For the revenues listed in question 6.a.,
please give the approximate percentage derived from
each of the activities listed in Question 4:
8.
Applicant is:
Corporation
Partnership
Individual
9.
Year Established:
10.
Is the Applicant Firm controlled, owned
or associated with any other firm, corporation or company?
Yes
No
If YES, attach an explanation:
Are any activities listed in Question
4 provided to such business enterprise?
Yes
No
11a.
Number of principals, partners, officers
and professional employees
11b.
Number of non-professional employees
(clerks, secretaries, etc.):
12.
Please provide the following:
13.
To what professional association(s) does
the Applicant Firm belong?
14.
Please include a list of Applicant Firm's
five (5) largest jobs or projects during the past three
(3) years. Please give, in detail: 1) project/client
name; 2) the nature of the services performed for the
client; and 3) the revenues obtained from those services.
15.
Does the Applicant Firm use a written
contract with client?
In all cases
Sometimes
Never
Please attach a copy of your standard
contract(s).
16.
What percentage of the Applicant Firm's
business involves subcontracting of work to others?
Does the Applicant Firm provide professional
services to business entities in which it retains an
ownership interest?
Yes
No
If YES, please explain:
17.
Has any similar insurance ever been declined
or cancelled?
Yes
No
If YES, please explain:
18.
Is similar insurance currently in force?
Yes
No
If YES, please provide:
Description of services being covered:
Name of Insurer:
Expiration Date:
Prior Acts / Retro. Date:
Limit:
Deductible:
Premium:
Length of time coverage has been in force:
19.
Attach most recent audited financial
statements (or recent tax returns) and descriptive or
promotional materials.
19a.
Estimated Gross receipts for current fiscal period:
19b.
Estimated Cost of Goods Sold for current fiscal period:
20.
Have any of the individuals listed in
question No.12 ever been the subject of disciplinary
action by authorities as a result of their professional
activities?
Yes
No
If YES, please explain:
21.
Does any person to be insured have knowledge
or information of any act, error or omission which might
reasonably be expected to give rise to a claim against
him/her?
Yes
No
If YES, please complete a Supplemental
Claim Information form for each.
22.
After inquiry have any claims been made
against any proposed Insured(s) during the past three
(3) years?
Yes
No
If YES, please complete a supplemental
Claims Information form for each claim.
How many claims have been made in the last three (3) years?
It is understood and agreed that with respect to questions
20,21 and 22, that if such knowledge or information exists
any claim or action arising there from is excluded from
this proposed coverage.
The Applicant hereby acknowledges that he/she/it is aware
that the limit of liability shall be reduced, and may be
completely exhausted, by the costs of legal defense and,
in such event, the Insurer shall not be liable for the costs
of legal defense or for the amount of any judgment or settlement
to the extent that such exceeds the limit of liability.
The Applicant hereby further acknowledges that he/she/it
is aware that legal defense costs that are incurred shall
be applied against the deductible amount.
I HEREBY DECLARE that, after inquiry, the above statements
and particulars are true and I have not suppressed or misstated
any material fact and that I agree that this application
shall be the basis of the contract with the Underwriters.
