VISTAGE CHAIR PROFESSIONAL LIABILITY INSURANCE APPLICATION

IMPORTANT! The rates shown in the matrix below are ONLY available for Applicants with the following characteristics:

Generates no more than $400,000 in revenues annually
Does not seek insurance for Executive Coaching/Consulting services outside of those performed on behalf of Vistage
No prior insurance claims in the last 5 years
Requires no more than 3 years Prior Acts
Not located in Kentucky

BY CHECKING THE BOX BELOW, APPLICANT WARRANTS THAT HE/SHE UNDERSTANDS THE RESTRICTIONS LISTED ABOVE. NO APPLICATION WILL BE CONSIDERED FOR COVERAGE UNDER THIS INITIATIVE UNLESS THIS WARRANTY HAS BEEN PROVIDED.

NOTE: APPLICANTS FALLING OUTSIDE OF THE PARAMETERS LISTED ABOVE MAY STILL BE ELIGIBLE FOR PROFESSIONAL LIABILITY INSURANCE THROUGH FOX POINT PROGRAMS. CONTACT US FOR DETAILS.

Applicant Name:

dba Name:

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Vistage Chapter

2. What were the Applicant’s expected revenues over the last 12-month period?

3. Is E&O Coverage currently in-force?

If “Yes”, provide details:

COMPANY

LIMITS

DEDUCTIBLE

PREMIUM

EXPIRATION DATE

Date

RETRO DATE

Date

4. Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or organization proposed for this insurance or any predecessor organization in the past five (5) years?

5. Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, error, omission, circumstance, or situation that might provide grounds for any claim under the proposed insurance?

If Questions 4 or 5 answered “Yes”, provide additional information below:

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 MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.

Date

Applicant’s Authorized Signature

1. Contact Information