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
I Understand
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.
1. Contact Information
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?*
YesNo
If “Yes”, provide details:
COMPANY*
LIMITS*
DEDUCTIBLE*
PREMIUM*
EXPIRATION DATE*

MonthDayYear
Date
RETRO DATE*

MonthDayYear
Date
YesNo
YesNo
If Questions 4 or 5 answered “Yes”, provide additional information below:*
4: 5:
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*

MonthDayYear
Date
Applicant’s Authorized Signature*

Clear
Should be Empty:

1. Contact Information