R.R.I.S. Miscellaneous Professional Liability Application   

Please provide your following contact information:   

 (The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
FEIN #
Work Phone
FAX
E-mail
URL

What is the form of your business?

Individual/Sole Proprietor
Partnership
Corporation
Limited Liability Company

What year was your business established ?

What is your proposed effective date of coverage?

Limit of Liability desired (each claim/annual aggregate):

$500,000/$500,000      $500,000/$1,000,000    $1,000,000/$1,000,000  $1,000,000/$2,000,000
$1,000,000/$3,000,000  

Policy Type:

Claims-Made
Occcurrence

Professional activities for which coverage is desired:

If applicant is engaged in any business or professional activity other than in Question 6, please explain and include estimated annual receipts.

Gross receipts for the past three (3) years and projected gross receipts of current year for the professional activities described in Question 6:

             Year                                                                        Gross Receipts

For the current year projected Gross Receipts, please give the approximate percentage derived from each activity listed in Question 6:

            Service Provided                                                    Approximate % of current Est. Receipts

Is the applicant controlled, owned or associated with any other firm, corporation or company?

Yes
No

If yes, please provide full details:

Are any of the services described in Question 6 provided to business enterprises in Question 11? If yes, please provide details:

What professional associations do you belong to:

Do you use a written service contract?

Always
Sometimes
Never

Please attach a sample copy of the contract used.

Number of principals, partners, officers and professional employees providing service to clients:

Number of Clerical employees (clerks, secretaries, etc.)

Describe any other employees:

Please provide the following information

:        Name of Partner, Principal      Professional Qualifications        Date Qualified    Years Experience    How long as a Partner/Principal?

           or Key Employee

Please list five (5) of the largest projects handled during the past three (3) years:

            Project/Client Name                        Nature of services performed                                                        Revenues from services

What percentage of your business involves subcontracting work to others?

Are certificates of insurance, evidencing professional insurance, required of your subcontractors?

Yes
No

Does Sub name you as additional insured on professional policy?

Yes
No

Does contract with Sub contain hold harmless in applicant's favor?

Yes
No

Has any insurance company or insurer declined, canceled or refused to renew any similar insurance for you during the past five (5) years?

Yes
No

If yes, please provide details:

Prior five (5) years Professional Liability Insurance carriers:

            Company Name                    Policy Period        Limit        Deductible        Claims-Made                Annual Premium

                                                                                                                             or Occurrence

If any claims have been made during the past five (5) years against the applicant, any of the present partners, employees or office workers, or to your knowledge, against any past directors, partners, officers, or employees, please describe here:

Are you aware of any facts or circumstances, or any allegations or contentions, of any incident which may result in any claim being made against the applicant, or any of its past or present partners, executive officers, directors, office workers or employees, any predecessors in business, or against any corporation that the applicant was formerly employed by?

Yes
No

If Yes, please provide details on a separate page.

It is agreed that if such knowledge exists, any claim or action arising there from is excluded from this proposed coverage.

Please submit the following additional information with this application:

(1) A brief resume of all principals, partners and officers.

(2) Copies of :

    (a) advertisements, brochures and descriptive literature;

    (b) sample service contract between applicant and client; and

    (c) latest financial data (annual report and/or balance sheet)

 

Signing this form does not bind you to complete the insurance. Coverage will become effective upon approval of the application and issuance of the policy. It is agreed that this form will be the basis of a claims-made contract.  Should a claims-made policy be issued, this form will be attached to and become a part of the policy.

 

FRAUD WARNING

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

The answers given to all the questions in this application are complete and correct to the best of my knowledge.

 

 

______________________________________________        ______________________________________

SIGNATURE OF APPLICANT                                                    DATE