• Format: (000) 000-0000.
  • 3. Date Established*
     / /
  • 4. Is the Applicant controlled, owned, affiliated, or associated with any other entity?*
  • 5. Does the Applicant have any subsidiaries?*
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  • 6. Applicant is:*
  • Does the Applicant seek a quote for Employment Practices Liability Insurance?*
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  • *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.

  • 9. Provide Applicant's gross annual revenues attributable to the following years:

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  • 11. Does the Applicant use Independent Contractors?*

  • If Yes, please answer the following questions regarding the use of independent contractors:

  • b. Are all sub-contractors required to carry E&O Insurance?*

  • 12. Please answer the following questions regarding contractual procedures:

  • a. A written contract is used:*
  • b. Are all written contracts reviewed by legal counsel?*
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  • 14. Does Applicant have a current Professional Liability policy in place?*

  • If Yes, provide the following information about the Applicant's current Professional Liability Insurance:

  • Retroactive date on policy*
     / /
  • Has any Errors & Omissions or Professional Liability Insurance issued to the Applicant ever been declined, cancelled, or non-renewed?*
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  • If the answer to 15a, 15b, or 15c is Yes, you will be required to complete the Supplemental Claims Questionnaire at the end of this application for each Claim, Notice, or Circumstance.

  • 16. Please select the Limit of Liability you would like quoted (select up to 3)
  • Are you an insurance agent submitting on behalf of your client?*
  • Format: (000) 000-0000.

  • NOTICE TO ALL OTHER APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS INFORMATION FOR THE PURPOSE OF MISLEADING, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

    BY SIGNING THIS APPLICATION, THE APPLICANT REPRESENTS TO THE COMPANY THAT ALL STATEMENTS MADE IN THIS APPLICATION AND ATTACHMENTS HERETO ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS HAVE BEEN MISSTATED OR MISREPRESENTED IN THIS APPLICATION, SUPPRESSED OR CONCEALED. THE UNDERSIGNED AGREES THAT IF AFTER THE DATE OF THIS APPLICATION AND PRIOR TO THE EFFECTIVE DATE OF ANY POLICY BASED ON THIS APPLICATION, ANY OCCURRENCE, EVENT, OR OTHER CIRCUMSTANCE SHOULD RENDER ANY OF THE INFORMATION CONTAINED IN THIS APPLICATION INACCURATE OR INCOMPLETE, THEN THE UNDERSIGNED SHALL NOTIFY THE COMPANY OF SUCH OCCURRENCE, EVENT OR CIRCUMSTANCE AND SHALL PROVIDE THE COMPANY WITH INFORMATION THAT WOULD COMPLETE, UPDATE, OR CORRECT SUCH INFORMATION. ANY OUTSTANDING QUOTATIONS MAY BE MODIFIED OR WITHDRAWN AT THE SOLE DISCRETION OF THE COMPANY.

    COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT’S ACCEPTANCE OF THE COMPANY’S QUOTATION IS REQUIRED BEFORE THE APPLICANT MAY BE BOUND AND A POLICY ISSUED. THE APPLICANT AGREES THAT THIS APPLICATION, IF THE INSURANCE COVERAGE APPLIED FOR IS WRITTEN, SHALL BE THE BASIS OF THE CONTRACT WITH THE INSURANCE COMPANY, AND BE DEEMED TO BE A PART OF THE POLICY TO BE ISSUED AS IF PHYSICALLY ATTACHED THERETO. THE APPLICANT HEREBY AUTHORIZES THE RELEASE OF CLAIMS INFORMATION FROM ANY PRIOR INSURERS TO THE COMPANY.

  • Date (MM/DD/YY)*
     / /

  • Date of the alleged act, error, or omission*
     / /
  • Is this a*
  • Is this matter settled?*
  • d. Was the Applicant insured under a Professional Liability policy at the time of the incident?*

  • THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.

    THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIALTOTHE ACCEPTANCE OFTHE RISK OR HAZARD ASSUMED.

  • Date*
     / /
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  • Should be Empty: