ERRORS AND OMISSIONS APPLICATION

Insured Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List all subsidiary companies

Proposed coverage effective dates Date to Date

This is a claims made policy. We must also write the general liability coverage and the dates should be concurrent.

Does this insured have a previous and/or current Errors and Omission Liability Insurance policy or endorsement?

If yes, please advise limits, deductible and policy expiration.

Date

Website Address

Description of services coverage is requested for:

Applicable General Liability Classification Codes:

Insured's Annual Receipts:

Limits requested on this proposed policy:

Optional Deductibles

Has any errors and omissions claim been made or is now pending against the above insured?

If yes, please provide details:

Has any similar insurance ever been declined, cancelled or non-renewed for the proposed insured (not applicable in MO):

If yes, please provide details:

Has the proposed insured ever done any design/build work or do they plan on doing any in the future?

If yes, please answer the following questions: Number of years experience in design work

Are there any engineers or draft persons on your staff?

If yes, how long have they been doing this type of work and what is their experience?

What size (largest) and types of jobs have they done in the past?

Who usually approves plans to obtain building permits if needed?

RMBIA Service Rep Fill out this form?

Have you read the T&C?

By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.