Fillable APPLICATION - MO COVER-PRO made against you, and (Philadelphia Insurance Companies)

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APPLICATION - MO COVER-PRO made against you, and (Philadelphia Insurance Companies)

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COVER-PRO
SM
APPLICATION - MO
NOTICE: This professional liability coverage is provided on a claims-made basis; therefore, claims which are first
made against you, and reported to the Company, during the policy period are eligible for coverage, subject to policy
provisions.
1.
Name of the Applicant Firm:
2.
Applicant principal location:
Street Address:
City:
State:
Zip Code:
Website:
3.
Risk Management Contact:
Risk Managements Email:
4.
Date established:
Telephone:
5.
6.
Yes
No
7.
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.
Subsidiary(ies): (Please note that our policy does not provide automatic coverage for subsidiaries)
8.
Yes
No
9.
a.
Principals, Partners or Officers:
b.
Professionals (not included in A):
c.
Support staff (including part-time):
d.
Part-time professionals (less than 20 hr/wk):
TOTAL:
PI-PLSP-3 MO (09/16)
Page 1 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
E-mail address:
Risk Management’s Phone:
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10.
Yes
No
11.
Dates of the Applicant’s current fiscal period:
From:
To:
PAST FISCAL YEAR
CURRENT FISCAL YEAR
ESTIMATE – NEXT YEAR
Total Gross Annual Revenue
$
$
$
12.
%
%
%
%
%
Other (specify):
%
13.
employee of your firm is also a principal, partner, officer, employee or a more than three
Yes
No
a.
Client name:
b.
Applicant’s relationship with the client:
c.
Approximate annual gross revenue generated from this client: $
14.
Yes
No
a.
Client name:
b.
Services rendered:
c.
How long do you expect this relationship to continue?
15.
Describe the Applicant’s three (3) largest jobs or projects during the past three (3) years.
Client name:
Services rendered:
Total gross billings: $
Client name:
Services rendered:
Total gross billings: $
Client name:
Services rendered:
Total gross billings: $
PI-PLSP-3 MO (09/16)
Page 2 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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16.
Yes
No
a.
Approximate percentage of billings attributable to independent contractors or sub-
consultants:
%
17.
Yes
No
18.
Yes
No
%
a.
Does the Applicant’s contract contain any of the following? (check all that apply)
Hold harmless or indemnification clauses in your favor
Guarantees or warranties
Hold harmless or indemnification clauses in your clients favor
Payment terms
A specific description of the services you will provide
19.
20.
Yes
No
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?
If yes, provide details. NOT APPLICABLE IN MISSOURI
21.
Yes
No
22.
Yes
No
23.
Name of Insurer:
Limit of Liability: $
Deductible: $
Premium: $
Policy period:
-
Name of Insurer:
Limit of Liability: $
Deductible: $
Premium: $
Policy period:
-
Name of Insurer:
Limit of Liability: $
Deductible: $
Premium: $
Policy period:
-
a.
Retro-active date on current policy:
24.
predecessor(s) or any past or present principal, partner, officer or employee within the
Yes
No
25.
omission, unresolved job dispute or any other circumstance that is or could be a basis for
Yes
No
PI-PLSP-3 MO (09/16)
Page 3 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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26.
Please indicate the number of claim supplemental forms attached to this application:
With regard to questions 24. and 25., it is understood and agreed that if any such claim, act, error,
omission, dispute or circumstance exists, then such claim and/or claims arising from such act, error,
omission, dispute or circumstance is exclu
ded from coverage that may be provided under this proposed
insurance and, further, failure to disclose such claim, act, error, omission, dispute or circumstance
may result in the proposed insurance being void, and/or subject to rescission.
Coverage requested:
LIMIT OF LIABILITY:
$250,000
$1,000,000
$4,000,000
$7,000,000
$10,000,000
$300,000
$2,000,000
$5,000,000
$8,000,000
$500,000
$3,000,000
$6,000,000
$9,000,000
DEDUCTIBLE:
$
Attach the following items in support of this application
1.
Applicant Firm’s statement of qualifications including resumes of all key (technical)
personnel along with any available marketing material or company brochures.
2.
A copy of the Applicant Firm’s formalized standard client contract.
3.
A copy of the outline from the Applicant Firm’s Quality Assurance / Quality Control
(QA/QC) manual.
PI-PLSP-3 MO (09/16)
Page 4 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any
attachments submitted with this Application) are true and complete and may be relied upon by Company * in quoting
and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the
Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance
Company
.
FRAUD NOTICE STATEMENTS
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
AGENCY PRODUCER
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FOR INSURANCE 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 THAT
PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT
INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO
EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
PI-PLSP-3 MO (09/16)
Page 5 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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ADDITIONAL INFORMATION
This pag
e may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
_____________________
_____________________
Signature Date
PI-PLSP-3 MO (09/16)
Page 6 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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APPLICATION - MO COVER-PRO made against you, and (Philadelphia Insurance Companies)

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Completed 7 November 2020

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