Fillable APPLICATION FOR PROFESSIONAL LIABILITY ERRORS & OMISSIONS INSURANCE (Risk Placement Services, Inc.)

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APPLICATION FOR PROFESSIONAL LIABILITY ERRORS & OMISSIONS INSURANCE (Risk Placement Services, Inc.)

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MPL 8/2011
Page 1 of 4
APPLICATION FOR PROFESSIONAL LIABILITY ERRORS & OMISSIONS INSURANCE
IF COVERAGE IS ISSUED, IT WILL BE ON A CLAIMS-MADE AND REPORTED BASIS
NOTICE: THIS INSURANCE COVERAGE PROVIDES THAT THE LIMIT OF LIABILITY AVAIALBLE TO PAY JUDGEMENT OR SETTLEMENTS
SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE
SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.
_________________________________________________________________________________________________________________________
1. NAME O
F APPLICANT:
_________________________________________________________________________________________
ADDRESS: ___________________________________________________
CITY: __________________________________________________________ STATE: __________ ZIP CODE: ________________
WEBSITE ADDRESS: ___________________________________________________________________________________________
2. LIMIT
OF LIABILITY DESIRED
$500,0
00
$1,000,000 $2,000,000 Other ___________________________
3. DEDUCTIBLE
$5,000 $10,000 $25,000 Other ___________________________
4. Please describe in detail the professional activities for which coverage is desired:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. Is the applicant engaged in any business or profession other than as described in Item 4? ________________________
If yes, please attach an explanation and estimated revenues.
6. List t
he total gross revenues for the past two years derived from those activities in Question 4. In addition, please list
projected revenues for the current year.
YEAR
AMOUNT
*If revenues are over $10,000,000 or if
deductibles of $25,000 or higher are
elected, please attach a copy of your
most recent financial statements.
a) Current Projected
$ ____________
b) _______________
$______________
c) _______________
$ ____________
MPL 8/2011
Page 2 of 4
6. d) In the last 12 months has the Insured had a positive Net Income? YES NO
positive Net Equity? YES NO
If No, please provide details including remedial actions taken.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
7. F
or the revenues listed in question 6a), please give the approximate percentage derived from each of the activities
listed in Question4:
ACTIVITY
% OF 6a) REVENUES
________________________
____________%
________________________
____________%
________________________
____________%
________________________
____________%
8. Does the applicant Firm provide professional services to business entities in which it retains an ownership?
YES
NO If yes, please explain
______________________________________________________________________________________________________
9.
Year Established: _________________________________
10.
Is the Applicant Firm controlled, owned or associated with any other firm, corporation or company?
YES
NO If yes, attach an explanation. Are any activities listed in Question 4 provided to such business
enterprise? YES NO
11.
a) Numbers of principals, partners, officers and professional employees directly engaged in providing services to
clients: ___________
b) Number of non-professional employees (clerks, secretaries, etc.): ____________
12. Please provide the following:
Name in full of ALL
Partners/Principals/
Key Employees
PROFESSIONAL
QUALIFICATIONS
HOW LONG IN
PRACTICE
HOW LONG AS
PARTNER/
PRINCIPAL
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
MPL 8/2011
Page 3 of 4
13. T
o what professional association(s) does the Applicant Firm belong?
_
___________________________________________________________________________________________________
14.
Please include a list of Applicants Firm’s five (5) largest jobs or projects during the past three (3) years. Please giv
e,
i
n detail: 1) project/client name; 2) the nature of the services performed for the client; and 3) the revenues obtained
from those services.
__________________________________________________________________________________________________________________
______________________
____________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
_____________________
_____________________________________________________________________________________________
15.
Does the Applicant Firm use a written contract with client?
In all cases Sometimes Never
Please attach a copy of your standard contract(s).
16. Does the applicant use independent contractors? YES NO
If yes, please answer the following:
a. What percentage of the Applicant Firm’s business involve subcontracting work to others? ______%.
b. What type of services are performed by independent contractors? _______________________________________
__________________________________________________________________________________________________
c. Is proof that Independent Contractors carry professional liability required? YES NO
17. Has any similar insurance ever been declined or cancelled? YES (If yes, attach explanation.) NO
18. a. Is similar insurance currently in force? YES NO
If yes, please provide:
Description of services being covered: ______________________________________________________________
Name of Insurer: _________________________________________________________________________________
E
xpiration Date: __________________________________________________________________________________
Li
mit: $_______________ Deductible $_______________ Premium $_______________
Le
ngth of time coverage has been in force: ___________________________
18.
b. Give the following information for General Liability Coverage in force:
Carrier: ______________________ Limit: $____________________ Expiration Date: _______________
MPL 8/2011
Page 4 of 4
19. Ha
ve any of the individuals listed in question No. 12 ever been the subject of disciplinary action by authorities as a
r
esult of their professional activities?
YES NO If yes, please explain.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
20. Does any person to be insured have knowledge or information of any act, error or omission which might reasonably
be expected to give rise to a claim against him/her. YES NO If yes, please complete a Supplemental
Claim Information form for each.
21. A
fter inquiry have any claims been made against any proposed Insured(s) during the past three (3) years?
YES NO If yes, please complete a supplemental Claims Information form for each claim.
Also, how many claims have been made in the last three (3) years? _______________________
It is understood and agreed that with respect to questions 20, 21 and 22 above, that if such knowledge or
information exists any claim or action arising therefrom is excluded from this proposed coverage.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
The Applicant hereby acknowledges that he/she/it is aware that the limit of liability shall be reduced, and may be
completely exhausted, by the costs of legal defense and, in such event, the Insurer shall not be liable for the costs of legal
defense or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability.
The Applicant hereby further acknowledges that he/she/it is aware that legal defense costs that are incurred shall be
applied against the deductible amount.
I HEREBY DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or
misstated any material fact and that I agree that this application shall be the basis of the contract with the Underwriters.
Signature of person authorized to execute on behalf of the Applicant:
________________________________________ Title ______________________________ Date________________________
This Application Form duly completed, together with any supplementary information, must be signed by the person
indicated.
Signing of this form does not bind the Applicant or the Underwriters to complete the insurance.
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APPLICATION FOR PROFESSIONAL LIABILITY ERRORS & OMISSIONS INSURANCE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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