Fillable KINSALE Misc Professional App Amended-1 - KINSALE_Misc_Professional_App_Amended

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KINSALE Misc Professional App Amended-1 - KINSALE_Misc_Professional_App_Amended

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MISCELLANEOUSPROFESSIONALLIABILITYAPPLICATION

1. Legalnameofthebusinesswhoistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:

_________________________________________________________________________________________________

2. Pleaselistallotherbusiness/dbanamesforwhichyouareseekingcoverageunderthispolicy:  



3. Corporation  Individual Partnership Municipality ForProfit JointVenture

Other:

4. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunderandforwhichno

coverageisbeingappliedfor.



5. Primarylocationaddress:

6. Datebusinessoriginallyestablished:__________________________

7. Totalnumberofbranches?  Listalladdressesforadditionalbranches:

_______

8. Whatisyourweb‐siteaddress?www.  __________________________________________________

9. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No 

mergedorconsolidatedwiththeentitywithinthelast5years?

10. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes

No 

11. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes

No 

mergedorconsolidatedwithyou?

Forquestions9‐11,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:





12. Pleaselistallassociationsofwhichyouareamember:





1. Pleaseprovideacompletenarrativedescriptionofyouroperationsandservicesyouoffer.





2. Pleasehelpusunderstandthesizeofyourbusiness.Pleaseprovideprojectionsifanewbusiness:

a) TotalGrossRevenue:Past12months:$  Estimatednext12months:$

b) TotalPayroll:Past12months:$  Estimatednext12months:$

c) Doesanysingleclientprovideover25%ofgrossreceipts? Yes No 

If“Yes,”pleaseprovidethenameoftheclient,thedollarvalueofthiswork,andadescriptionofthework

performed:



APPLICANT’SINFORMATION

GENERALINFORMATION

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page2of4



3. Doyousubcontractanyofyourprofessionalservicestootherprofessionals:Yes

No 

Ifyouanswered“Yes”,doyouuseawrittencontractYes

No 

Doyourequiresubcontractorstocarryinsurancecoveragethatisequaltoorbroaderthanyours?Yes

No 

Doyourequireyoursubcontractstonameyouasanadditionalinsuredontheirpolicies? Yes

No 



4. Providedetailsofthefive(5)largestprojectsundertakenduringthelast12months.Ifastart‐up,pleaseinstead

provideaprojectionofthetypeandsizeofprojectscontemplated:



NameofClient DescriptionofServices GrossReceipts LengthofContract

 







5. Pleaseprovidethetotalnumberof:Officers/Partners  ProfessionalStaff OtherStaff  



KeyStaff ProfessionalLicensesHeld YearsofExperience LengthofEmployment

  



6. Pleaselistanyindustrygroupsorassociationsthatyoubelongto:





1. Provideyourentity’srecentinsurancehistorybelow.



 

InsuranceCompany

LimitsPer

Claim/Aggregate

PolicyPeriod

(Month/Day/Year) AnnualPremium

CurrentYear 

PreviousYear1 

PreviousYear2 

PreviousYear3 

PreviousYear4 



2. Ifyouarecurrentlyinsuredforerrors&omissionscoverage,whatisyourpolicy’sretroactive/prioractsdate?

(month/day/year)_____/_____/_______Ifthereisnoretroactivedate,pleasecheckhere.







3. Areyoubeingcanceledornon‐renewedbyyourcurrentprofessionalliabilitycarrier?

Yes No 

Ifyes,pleaseexplainwhy:      

    



4. Requestedlimits: $1M/$2M $2M/$2M (other)  



INSURANCEANDLOSSHISTORY

Page3of4



Requesteddeductible: $2,500 $5,000 $10,000 $25,000 Other$



6. Inthelastfive(5)years,haveanyclaimsbeenmadeagainstthepersonorentityapplyingforinsurance,oranyofyour

pastorpresentmembers,partners,officers,directors,employees,oranypredecessorsinbusiness? Yes

No 

 

If“yes”,pleaseprovidedetailsonaseparatepage.



7. Areyou,oranyofyourpartners,officers,directors,oremployees,awareofanycircumstances,acts,errors,omissions,

oranyallegationsorcontentionsofanyincidentwhichmayresultinaclaim? Yes

No 



If“yes”,pleaseprovidedetailsonaseparatepage.



8. Haveyou,oranyofyourpartners,officers,directors,oremployeesbeenthesubjectofanycomplaintorsubjecttoany

disciplinaryactionbyanystatelicensingagencyorotherregulatorybodyduringthepastfive(5)years?Yes

No 



If“yes”,pleaseprovideanexplanationofthecircumstancesandpenaltyinvolved.Ifavailable,pleaseprovideacopy

ofthecomplaint,yourresponse,andacopyoftheregulatorybody’sdecision.



FRAUDWARNING



NOTICETOALABAMA,ALASKA,ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA,IDAHO, ILLINOIS,INDIANA,IOWA, KANSAS,

MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH

CAROLINA,NORTHDAKOTA,OREGON,RHODEISLAND, SOUTH CAROLINA,SOUTHDAKOTA,TEXAS, UTAH, VERMONT,WASHINGTON,WESTVIRGINIA,

WISCONSIN, AND WYOMING APPLICANTS:In

some states, 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, for the purpose of misleading, conceals

informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceactwhich

isacrimeinmanystates.



NOTICETOCOLORADOAPPLICANTS: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 policy holder or

claimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholde rorclaimingwithregardtoasettlementorawardpayableforinsurance

proceedsshallbe

reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.



NOTICE TO DISTRICTOF COLUMBIA APPLICANTS:  WARNING:Itis a crime to provide falseor misleadinginformation toan insurerfor thepurpose of

defrauding the insurer or any other person. Penalties include imprisonment and/or fines.

In addition, an insurer may deny insurance benefits if false

informationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.



NOTICETOFLORIDAAPPLICANTS:Any personwhoknowinglyandwithintenttoinjure,defraudordeceive anyinsurancecompanyfiles a statementof

claimcontaininganyfalse,incompleteor

misleadinginformationisguiltyofafelonyofthethirddegree.



NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor

benefitisacrimepunishablebyfinesorimprisonment,orboth.



NOTICETO

KENTUCKYAPPLICANTS: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.



NOTICE

TO LOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.



NOTICETOMAINEAPPLICANTS: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denialofinsurancebenefits.



NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleadinginformationonanapplication

foraninsurancepolicyissubjectto

criminalandcivilpenalties.



NOTICE TO NEW MEXICO APPLICAN TS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmay

besubjecttocivilfinesandcriminalpenalties.



NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudan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alsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalue

oftheclaimforeachsuchviolation.

Page4of4



NOTICE TO OHIO APPLICANTS:Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an

applicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.



NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,

andwithintenttoinjure,defraudordeceiveanyinsurer,makesaanyclaim

fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.



NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance company, or

 other person, files an

application for insurance or statement of a 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thepersontocriminalandcivilpenalties.



NOTICE TO

 TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.



NOTICETOVIRGINIAAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformation

toaninsurancecompanyforthepurpose

ofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.



TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe

abovestatementsandparticularstogetherwit hanyattachedorappended

documentsaretrueandcompleteanddonotmisrepresent,misstateoromit

anymaterialfacts.

TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective

dateofanypolicyissuedpursuanttothisquestionnaire

andtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdrawn

baseduponsuchchangesatoursolediscretion.

Completion ofthis form doesnot bindcoverage. Applicant’sacceptance of thecompany’s quotationis required prior tobinding coverageandpolicy

issuance.



All written statements and materials furnished

 to the company in conjunction with this application are hereby incorporated by reference into this

applicationandmadeapartofthisapplication.



Applicant:   Title: 

 (MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)



Applicant’sSignature:   Date:   



Agent/BrokerName:     

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KINSALE Misc Professional App Amended-1 - KINSALE_Misc_Professional_App_Amended

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Completed 2 July 2020

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