FORTEGRA SELF RATING APP 1 - FoxPro Defender

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

Generates no more than $500,000 in revenues annually
No prior insurance claims in the last 5 years
Requires no more than 3 years Prior Acts
Risk not domiciled in AK, IA, KS, or KY
Professional Services provided are Consulting services only

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.

Applicant Name:*

dba Name:*

Business Address

Street Address

City

State / 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

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*

Date

RETRO DATE*

Date

YesNo

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

YesNo

If "Yes", please answer the following questions regarding their use:

a. The total percentage of work done by sub-contractors:*

YesNo

7. Please answer the following questions regarding contractual procedures:

AlwaysSometimesNever

YesNo

c. Percentage of contracts that limit Applicant's liability:*

YesNo

Agent Name*

Name of Agency*

Phone Number*

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

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter the email of the client that will sign this application. Clicking Submit will send a request for signature.

example@example.com

1. Contact Information

TO BE SIGNED BY THE APPLICANT ONLY