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

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.*

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.

Fax Number

Please enter a valid phone number.

Email*

example@example.com

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

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

YesNo

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?*

YesNo

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?*

YesNo

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

6. Does the Applicant use Independent Contractors?*

YesNo

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

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

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

YesNo

7. Please answer the following questions regarding contractual procedures:

a. A written contract is used:*

AlwaysSometimesNever

b. Are all written contracts reviewed by legal counsel?*

YesNo

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

Are you an insurance agent submitting on behalf of your client?*

YesNo

Agent Name*

Name of Agency*

Phone Number*

Please enter a valid phone number.

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