Professional Liability

Personal Information
First Name Required Input Required
Last Name Required Input Required
Name of Application Firm Required Undefined
Street Required Input Required
City Required Input Required
State Required Input Required	select AL AK AZ AR CA CO CT DE FL GA HI ID IA IL IN KS KY LA ME MD MA MI MN MS MO MT NC ND NE NV NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Website Required Undefined
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Primary Phone Number Required Input Required Please enter a valid phone number
Date Established Required Undefined
Describe the Applicant's nature of business: Required Undefined
Is the Application Firm controlled, owned, affiliated or associated with any other firm, corporation or company? Required Undefined	Yes No
If yes, please explain. Required Undefined
Please list the address(es) of all branch offices and/or subsidiaries. Include a brief description of their operations and indicate if coverage is desired for these offices. Branch office(s): Required Undefined
Subsidiaries: Required Undefined
During the past five (5) years has the name of the firm been changed or has any other business(es) been acquired, merged into or consolidated with the applicant firm? Required Undefined	Yes No
If yes, provide a complete explanation detailing any liabilities assumed. Required Undefined
Staffing - Provide a breakdown of the Applicants staff into the following categories:
A. Principals, Partners, or Officers Required Undefined
B. Professionals (not included in A): Required Undefined
C. Support Staff (including part-time): Required Undefined
D. Part-time professionals(less than 20 hr/wk): Required Undefined
TOTAL: Required TOTAL: is required.
Are any staff members considered "Licensed Professionals" or do any staff members hold any professional designations or belong to any professional societies/associations? Required Undefined	Yes No
If yes, provide the individual's name and designation/affiliation: Required Undefined
Dates of the Applicant's current fiscal period: (From - To) Required Undefined
Past Fiscal Year (Total Gross Annual Revenue) $ Required Undefined
Current Fiscal Year (Total Gross Annual Revenue) $ Required Undefined
Estimate - Next Year (Total Gross Annual Revenue) $ Required Undefined
Provide the percentage of the Applicant's gross annual revenue from the last fiscal period attributable to the following:
Percentage to Federal goverment: Required Undefined
Percentage to state, county, or local goverment and agency thereof: Required Undefined
Percentage to institutional (schools, hospitals, etc) Required Undefined
Percentage to lending institutions: Required Undefined
Percentage to manufacturing: Required Undefined
Percentage to Other:(specify) Required Undefined
Does the Applicant provide services for any clients in which a principal, partner, officer or employee of your firm is also a principal, partner, officer, employee or a more than three (3)% shareholder of said client? Required Undefined	Yes No
If yes, please provide the Client Name, Applicant's relationship with client, and approximate annual gross revenue generated from this client. Required Undefined
Were more than fifty (50)% of the Applicants total gross annual billings for any one year derived from a single client or contract? Required Undefined	Yes No
If yes, provide the client name, services rendered, and how long you expect the relationship to continue. Required Undefined
Describe the Applicant's three (3) largest jobs or projects during the past three (3) years.
Client name, services rendered, and total gross billings: Required Undefined
Client name, services rendered, and total gross billings: Required Undefined
Client name, services rendered, and total gross billings: Required Undefined
Does the Applicant utilize the services of independent contractors or sub-consultants? Required Undefined	Yes No
Approximate percentage of billings attributable to independent contractors or sub consultants. Required Undefined
Does the Applicant ever enter into contracts where their fees for services provided are contingent upon the client achieving cost reductions or improved operating results? Required Undefined	Yes No
If yes, provide a detailed description of such arrangements. Required Undefined
Does the Applicant secure a written contract or agreement for every project? Required Undefined	Yes No
If no, provide the percentage of your gross annual revenue where a written contract is secured. Required Undefined
Does the Applicant's contract contain any of the following? (check all that apply) Optional	Hold harmless clauses in your favor? Hold harmless clauses in your clients favor? A description of the services you will provide? Guarantees or warranties? Payment terms? Hold down the Ctrl Key to make multiple selections.
Describe steps taken to minimize / manage business risks: Required Undefined
Has any policy or application for similar insurance on your behalf or on the behalf of any of your principals, partners, officers, employees, or on behalf of any predecessors in business ever been declined, canceled, or renewal refused? Required Undefined	Yes No
If yes, please explain. Required Undefined
Does the applicant currently carry commercial general liability insurance? Required Undefined	Yes No
Please provide the following information on your professional liability (E&O) insurance for the past three (3) years:
Name of insurer, limit of liability, deductible, premium, and policy period. Required Undefined
Name of insurer, limit of liability, deductible, premium, and policy period. Required Undefined
Name of insurer, limit of liability, deductible, premium, and policy period. Required Undefined
Retro-active date on current policy: Required Undefined
Have any claims, suits, or demands for arbitration been made against the Applicant, it's predecessor(s) or any past or present principal, partner, officer or employee within the past five (5) years? If yes, complete a Claim Supplement form for incidents. Required Undefined	Yes No
Having inquired all princiapls and officers, are you aware of any act, error, omission, unresolved job dispute or any other circumstance what is or could be a basis for a claim under the proposes insurance? If yes, complete a Claim Supplement form. Required Undefined	Yes No
Coverage Requested:
LIMIT OF LIABILITY: Required Undefined	select $250,000 $300,000 $500,000 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000 $9,000,000 $10,000,000
Deductible: $ Required Deductible $ is required.
Enter Validation Code Required

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