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

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

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COVER-PRO
SM
APPLICATION
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:
E-mail address:
3.
Risk Management Contact:
Risk Management’s Phone:
4.
Date established:
Telephone:
5.
Describe the Applicant’s nature of business:
6.
Is the Applicant Firm controlled, owned, affiliated or associated with any other firm,
corporation or company?
Yes
No
If yes, please provide an explanation.
7.
Branch Office(s):
8.
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?
Yes
No
If yes, provide a complete explanation detailing any liabilities assumed.
9.
Staffing- Provide a breakdown of the Applicant’s staff into the following categories:
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 (09/16)
Page 1 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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10.
Are any staff members considered “Licensed Professionals” or do any staff members
hold any professional designations or belong to any professional societies/ associations?
Yes
No
If yes, provide the individual’s name and designation/affiliation:
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.
Provide the percentage of the Applicant’s gross annual revenue from the last fiscal
period attributable to the following:
Federal government:
%
State, county or local government and agency thereof:
%
Institutional (schools, hospitals, etc…):
%
Lending institutions:
%
Manufacturing:
%
Other (specify):
%
13.
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?
Yes
No
If yes, please provide the following:
a.
Client name:
b.
Applicant’s relationship with the client:
c.
Approximate annual gross revenue generated from this client: $
14.
Were more than fifty (50)% of the Applicant’s total gross annual billings for any one year
derived from a single client or contract?
Yes
No
If yes, provide the following:
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 (09/16)
Page 2 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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16.
Does the Applicant utilize the services of independent contractors or sub-consultants?
Yes
No
a.
Approximate percentage of billings attributable to independent contractors or sub-
consultants:
%
17.
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?
Yes
No
If yes, provide a detailed description of such arrangements.
18.
Does the Applicant secure a written contract or agreement for every project?
Yes
No
(Please attach a sample copy)
If no, provide the percentage of your gross annual revenue where a written
contract is secured:
%
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.
Describe steps taken to minimize / manage business risks:
20.
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?
Yes
No
If yes, provide details.
21.
Does the Applicant currently carry commercial general liability insurance?
Yes
No
22.
Has the Applicant sued to collect past or overdue fees from clients within the past 2
years? If yes, please provide details on the Additional Information page below.
Yes
No
23.
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: $
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.
Have any claims, suits, or demands for arbitration been made against the Applicant, its
predecessor(s) or any past or present principal, partner, officer or employee within the
past five (5) years?
Yes
No
If yes, complete a Claim Supplement form for each incident.
25.
Having inquired all principals, partners and officers, are you aware of any act, error,
omission, unresolved job dispute or any other circumstance that is or could be a basis for
a claim under the proposed insurance?
Yes
No
If yes, complete a Claim Supplement form for each incident.
PI-PLSP-3 (09/16)
Page 3 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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26.
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 (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
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). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN,
VA, VT, WA AND WV).
APPL
ICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APP
LICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF
DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APP
LICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY
(IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPL
ICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL
OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL
THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APP
LICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES
OR A DENIAL OF INSURANCE BENEFITS.
APPL
ICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR OFFICER)
_______
______________________________________________________
SIGNATURE DATE
SEC
TION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(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)
PI-PLSP-3 (09/16)
Page 5 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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ADDITIONAL INFORMATION
Thi
s page 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 (09/16)
Page 6 of 6
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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APPLICATION COVER-PRO made against you, and reported to (Philadelphia Insurance Companies)

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Completed 7 November 2020

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