Fillable COVER-PRO APPLICATION - NY PLEASE READ THIS POLICY (Philadelphia Insurance Companies)

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COVER-PRO APPLICATION - NY PLEASE READ THIS POLICY (Philadelphia Insurance Companies)

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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:
Risk Managements Email:
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.
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):
Subsidiary(ies): (Please note that our policy does not provide automatic coverage for subsidiaries)
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 NY (09/17)
Page 1 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
COVER-PRO
SM
APPLICATION - NY
PLEASE READ THIS POLICY CAREFULLY. T HIS PROFESSIONAL LIABILITY COVERAGE IS
PROVIDED ON A CLAIMS-MADE BASIS; THEREFORE CLAIMS WHICH ARE FIRST MADE
AGAINST YOU DURING THE POLICY PERIOD, ANY SUBSEQUENT RENEWAL, OR ANY
APPLICABLE EXTENDED REPORTING PERIOD ARE ELIGIB
LE FOR COVERAGE, SUBJECT TO
TH
E POLICY PROVISIONS.
THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE
REDUCED BY AMOUNTS INCURRED FOR DEFENSE COSTS. FURTHER NOTE THAT AMOUNTS
INCURRED FOR SUCH COST SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.
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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?
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?
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?
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 NY (09/17)
Page 2 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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16.
Does the Applicant utilize the services of independent contractors or sub-consultants?
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?
No
If yes, provide a detailed description of such arrangements.
18.
Does the Applicant secure a written contract or agreement for every project?
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?
No
If yes, provide details.
21.
Does the Applicant currently carry commercial general liability insurance?
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.
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?
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?
No
If yes, complete a Claim Supplement form for each incident.
PI-PLSP-3 NY (09/17)
Page 3 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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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 NY (09/17)
Page 4 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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FRAUD STATEMENT AND SIGNATURE SECTIONS
PI-PLSP-3 NY (09/17)
Page 5 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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
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 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)
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ADDITIONAL INFORMATION
This 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 NY (09/17)
Page 6 of 6
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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COVER-PRO APPLICATION - NY PLEASE READ THIS POLICY (Philadelphia Insurance Companies)

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Completed 7 November 2020

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