Fillable COVER-PRO RENEWAL APPLICATION - VT (Philadelphia Insurance Companies)

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COVER-PRO RENEWAL APPLICATION - VT (Philadelphia Insurance Companies)

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The COVER-PRO RENEWAL APPLICATION - VT (Philadelphia Insurance Companies) form is 5 pages long and contains:

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  • 18 check-boxes
  • 98 other fields

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1. Name of the Applicant Firm:
2. Applicant principal location:
Street Address:
City:
Website:
3. Risk Management Contact: Risk Management’s Phone:
Risk Management 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, 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 year has the Applicant Firm’s name 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.
State: Zip Code:
E-mail address:
COVER-PRO
SM
RENEWAL APPLICATION - VT
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.
PI-PLSP-3 RNWL VT (09/16)
Page 1 of 5
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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9. Staffing- Provide a breakdown of the Applicant’s staff into the following categories:
A.
Principals, Partners or Officers:
Support staff (including part-time):
B.
Professionals (not included in A):
Part-time professionals (less than 20 hr/wk):
TOTAL:
10.
Dates of Applicant Firm’s current fiscal period:
From:
To:
PAST FISCAL YEAR
CURRENT FISCAL YEAR
ESTIMATE - NEXT YEAR
Total Gross Annual Revenue
$
$
$
11.
For the gross annual revenue listed in question 9, please give the approximate
percentage derived from each service you provide.
Service:
Percent of Revenue:
%
Service:
Percent of Revenue:
%
Service:
Percent of Revenue:
%
Service:
Percent of Revenue:
%
To enter more information, please use the separate page attached to the application.
12.
Was more than fifty (50)% of the Applicant’s total gross annual revenue 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?
13.
Describe the Applicant Firm’s three (3) largest jobs or projects since your last renewal.
Client name:
Services rendered:
Total gross billings: $
Client name:
Services rendered:
Total gross billings: $
Client name:
Services rendered:
Total gross billings: $
PI-PLSP-3 RNWL VT (09/16)
Page 2 of 5
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
Clear Application
Print Application
14.
Does the Applicant utilize the services of independent contractors or sub-consultants?
Yes
No
a.
Approximate percentage of gross annual revenue attributable to independent
contractors or sub-consultants: %
15.
Does the Applicant ever enter into contracts where your 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.
16.
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: %
17.
Do the Applicant’s contracts contain any of the following? (check all that apply)
Hold harmless or indemnification clauses in the Applicant’s favor
Guarantees or warranties
Hold harmless or indemnification clauses in your Client’s favor
Payment terms
A specific description of the services the Applicant will provide
18.
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:
19.
Is the Applicant seeking any changes to the expiring policy limit or deductible?
If yes, please indicate the desired limit and retention:
Yes
No
Expiring limit:
Expiring deductible:
Professional liability coverage requested:
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
Requested Deductible: $
If question #19 was answered yes and increased limits are sought, please answer the
following question:
20.
Solely with respect to any higher limits requested or that may ultimately be
issued for the proposed renewal, is the Applicant or any person proposed for
this insurance aware of any fact, circumstance, situation, event or act that
reasonably could rise to a claim against them under the professional liability
coverage?
Yes
No
If yes, please provide details the Additional Information page below.
21.
Do you currently carry commercial general liability insurance?
Yes
No
22.
Has the Applicant sued to collect past or overdue fees from clients within the past two
(2) years?
Yes
No
If yes, please provide details on the Additional Information page below.
PI-PLSP-3 RNWL VT (09/16)
Page 3 of 5
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
Clear Application
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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
ADDRESS (STREET, CITY, STATE, ZIP)
PI-PLSP-3 RNWL VT (09/16)
Page 4 of 5
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and
subject to penalties under state law.
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ADDITIONAL INFORMATI
ON
This page may be u
sed to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
S
ignature Date
PI-PLSP-3 RNWL VT (09/16)
Page 5 of 5
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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Completed 7 November 2020

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