FOXPRO DEFENDER ERRORS & OMISSIONS APPLICATION

1. Name of Applicant*
2. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Web Site
E Mail*
example@example.com
3. Date Established*

MonthDayYear
Date
If the date is less than 3 years ago, provide resume of a principal or partner.
4. Is the Applicant controlled, owned, affiliated, or associated with any other entity?*

YesNo
If "Yes", provide name(s) and relationship*
5. Does the Applicant have any subsidiaries?*

YesNo

6. Applicant is:*

CorporationPartnershipIndividualLLCNon-Profit
7. Total Number of Employees*
Does the Applicant seek a quote for Employment Practices Liability Insurance?*

YesNo

8. List all professional services for which coverage is desired (write n/a in unfilled cells)*: *

*This form is not valid for all classes, including but not limited to: Abstractors, Title Agents, Real Estate, Attorneys/Lawyers. Please visit the “Business Type” tab on our website to complete the correct application for those classes. Please note this online form is a preliminary step to provide Underwriting with information needed to determine risk eligibility. Not all professional services will be eligible for our in-house program, therefore you may be required to complete an additional full application to be considered for quoting.
Total Professional Service Revenue:
Total must equal 100% before proceeding

	Subsidiary Name	% Ownership	Created Date	Services Performed
1
2

	Yes	No
a. Date-stamp incoming mail?
b. Maintain files on all clients?
c. Document all business-related phone conversations?
d. Retain records in accordance with the applicable Statute of limitations/minimum 3 years?
e. Does Applicant have a process in place to handle client complaints?
f. Does Applicant require continuing education for all professional employees?

	Yes	No
a. Do any principals, directors, officers, partners, employees, or independent contractors of the Applicant have knowledge or information of any actual or alleged acts, errors, omissions, offenses, or circumstances which might reasonably be expected to give rise to a claim against the Applicant?
b. During the past five years, has the Applicant, or any of its predecessors in business, subsidiaries, or affiliates, or any of the principals, directors, officers, partners, employees, or independent contractors ever been subject to a disciplinary action as a result of professional activities?
c. During the past five years, have any suits or claims been brought against the Applicant, any of its predecessors in business, subsidiaries, or affiliates, or any of the principals, directors, officers or employees?